Supported by mobile technology, trained health coaches and nurse care coordinators use home visits and telephone-based monitoring to identify and address declines in health status in recently discharged Medicare patients, leading to a significant reduction in readmissions and associated cost savings.
Nurse case managers at a Veterans Affairs hospital provide inhospital and post-discharge, telephone-based support to at-risk, community-dwelling patients and their caregivers, leading to better care transitions, fewer readmissions, and substantial cost savings.
Hospital-based interdisciplinary teams conduct daily reviews of real-time information on all inpatients ages 65 and older to identify and address risk factors that can lead to negative outcomes; the program reduced use of urinary catheters and increased use of physical therapy and social work evaluations.
A rehabilitation center's recuperative services unit uses a three-part protocol consisting of standardized assessments, palliative care consults and care plans, and root-cause analysis to reduce readmissions and improve staff morale.
A collaborative telemedicine program between a hospital and 10 nursing homes in rural communities prevents unnecessary transports of residents to the emergency department.
A Native American tribe–owned skilled nursing facility provides culturally competent services using a holistic approach to health and well-being, leading to high patient and family member satisfaction and low staff turnover.
Working in collaboration with geriatricians, a nurse practitioner comanaged the care of frail, elderly patients with any of five chronic conditions, leading to better adherence to recommended care processes.
A separate emergency center for older patients includes physical features to reduce anxiety and discomfort, staff trained in geriatric care, and routine followup monitoring after discharge, leading to high levels of patient satisfaction, detection of polypharmacy, increased patient volume, and a low rate of return visits.
An intensive, nurse-led care management program provided during and after hospitalization reduced readmissions, inpatient days, and care costs for high-risk seniors.
Primary care clinic nurses routinely assess the risk of falls in each patient, with real-time, easy-to-use clinical reminders sent to physicians for those at risk, thus allowing the initiation of risk-reduction interventions during the visit.