Emergency medical technicians screen rural-dwelling older adults for depression, medication-related problems, and falls. A case manager follows up with at-risk individuals to conduct an in-home assessment and provide needed referrals, leading to enhanced access to medical and social services and high levels of satisfaction.
A health system uses formal processes to track patients who meet core measure inclusion criteria, monitor gaps in care, investigate care variances, and share data and best practices, leading to a significant improvement in overall performance on the measures.
Immediate team debriefings after a cardiopulmonary resuscitation code event improve multiple aspects of the team's response to future codes and generate high levels of staff satisfaction.
A hospital uses a multidisciplinary team, standing orders and reminder systems, manual medication reconciliation, and system-wide quality improvement to significantly improve performance on core measures for heart attack, heart failure, pneumonia, and surgical care.
A transitional care program that identifies frail elderly patients in the hospital and provides them with in-home support after discharge significantly reduces readmissions and emergency department visits.
A dementia care facility takes a person-centered approach to caring for residents who exhibit challenging, aggressive behavior, leading to less need for psychiatric hospitalizations and behavior-related medications.
An electronic medical record–based system features “soft” and “hard” stop functions designed to ensure that clinicians perform medication reconciliation, leading to a rapid, significant, and sustained increase in adherence rates.
An adjustable “diet wheel” posted on each inpatient's doorway indicates which of 15 physician-ordered diets a patient should receive and prompts dietary staff to check that food trays match the ordered diet, leading to fewer diet-related miscommunications, mistakes, and interruptions.
Health system pharmacists telephone recently discharged patients to complete medication reconciliation and provide medication-related education, leading to significant reductions in readmission rates and high levels of patient satisfaction.
Liberty Country Living, a long-term care facility for people with dementia, offered nurse-managed care in a home-like setting, with a focus on supporting residents' capabilities. The facility had a high ratio of staff to residents and promoted social interaction, ambulation, and continence. The program helped residents stay ambulatory, maintain continence, avoid weight loss, avoid falls and disruptive behaviors, and reduce psychotropic medication use. After 5 years of operation, Liberty closed abruptly due to changes in State regulations.