Avoidable hospitalizations

Innovations

Primary Care–Based, Multidisciplinary Teams Provide Care Management Services to Complex Patients, Enhancing Patient Engagement and Reducing Hospitalizations 06/27/16

The San Francisco Health Network embeds multidisciplinary teams within primary care practices to provide “wraparound” services to medically and psychosocially complex patients. Made up of nurses,...

Specially Trained Paramedics Respond to Nonemergency 911 Calls and Proactively Care for Frequent Callers, Reducing Inappropriate Use of Emergency Services 12/19/14

Developed by Christian Hospital and Northwest HealthCare (a two-hospital system that is part of the BJC HealthCare System), Community Health Access Program is a mobile program that...

Physician-Led Clinics Offer Integrated, Coordinated Care to High-Risk Seniors Under Capitated Contracts, Leading to Strong Performance on Quality Metrics, Low Inpatient Use, and High Patient Satisfaction 11/04/14

ChenMed is a physician-led practice serving more than 20,000 Medicare-eligible seniors through 36 centers in six States. ChenMed offers integrated, coordinated care under capitated contracts...

Regional Commission Made Up of Diverse Stakeholders Enhances Access to Coverage and Services for Low-Income Residents, Reducing Readmissions and Emergency Department Visits 11/04/14

The St. Louis Regional Health Commission is a diverse consortium of collaborating stakeholders (providers, civic leaders, community activists, and local and State government officials) that...

Emergency Department–Based Asthma Clinic Improves Self-Management Behaviors and Reduces Acute Episodes for Low-Income, Inner-City Children and Teenagers 09/17/14

Through a program known as IMPACT DC (Improving Pediatric Asthma Care in the District of Columbia), Children's National Health System has an emergency department–based clinic that serves low-...

QualityTools

Managing Drug-Seeking Behaviors & Super Users in the Emergency Department 10/01/13

This guide for emergency department (ED) physicians, nurses, and caregivers includes information and tools for providing pain management care to “super users” in the ED. The guide offers an approach to understanding and managing two groups of...

Medical Respite Tool Kit 04/03/13

The purpose of the Medical Respite Tool Kit is to provide information and tools to help organizations and advocates plan, develop, and sustain medical respite programs. Medical respite care is acute and postacute medical care for homeless persons...

Coordinated-Transitional Care Toolkit 03/26/13

Coordinated-Transitional Care (C-TraC) is a low-resource, telephone-based, protocol-driven program designed to reduce 30-day rehospitalizations and to improve care transitions during the early posthospital period. The goal of this toolkit is to...

Heart Failure Self-Management—Caring for Your Heart: Living Well With Heart Failure 10/16/12

These health communication aides for clinicians can help them demonstrate to patients that organized self-management support can improve self-care behaviors and prevent hospitalizations.

These materials are available in two versions...

MONAHRQ® 4.0 09/18/12

My Own Network, powered by AHRQ (MONAHRQ), is a free software product that enables organizations—such as State and local data organizations, chartered value exchanges, hospital systems, and health plans—to input their own hospital administrative...

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