Transitions between settings

Innovations

Statewide Managed Care Plan for Foster Care Children Features Care Coordination and a Central Database, Leading to Improved Access and Mental Health Treatment 10/31/14

The Texas STAR (State of Texas Access Reform) Health Program is a statewide managed care plan for children and young adults in foster care and young adults who have aged out of the foster care...

Community-Based Health Coaches and Care Coordinators Reduce Readmissions Using Information Technology To Identify and Support At-Risk Medicare Patients After Discharge 03/23/14

Supported by mobile technology, trained health coaches at Elder Services of Merrimack Valley (an Area Agency on Aging in Northeastern Massachusetts) visit recently discharged Medicare patients in...

Primary Care Physician Communication With Patients at or Soon After Discharge Significantly Reduces Medication Discrepancies 03/17/14

Hospitalists at Northwestern Memorial Hospital contact the primary care physicians of patients with complex medication regimens who are about to be discharged from the hospital to their homes to...

Community Health Workers Embedded in Inpatient and Outpatient Clinical Teams Enhance Access to Primary Care and Improve Health Outcomes for Low-Income Patients 03/13/14

The University of Pennsylvania Health System embeds community health workers into its clinical teams at hospitals and medical offices. Following the Individualized Management for Patient-Centered...

Mental Health Center Provides Integrated Primary Care and Care Coordination to Medicaid Beneficiaries With Severe Mental Illness, Enhancing Access to Services and Improving Outcomes 12/20/13

As part of Rhode Island's implementation of the “health home” provision of the Affordable Care Act, The Providence Center (one of seven community mental health organizations in the State) offers...

QualityTools

IMPaCT™ Model Tool Kit 06/04/14

The IMPaCT ™ model is an evidence-based system for community health worker (CHW) recruitment, training, and care. In the IMPaCT model, CHWs provide tailored support to help high-risk patients achieve individualized health goals. This toolkit is...

Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals 04/24/14

The Roadmap for Hospitals was developed by The Joint Commission to inspire hospitals to integrate concepts from the communication, cultural competence, and patient- and family-centered care fields into their organizations. This guide provides...

Toolkit for the Follow-Up Care of the Premature Infant 03/12/14

This toolkit for health care professionals provides information and resources to help facilitate the care of premature infants and improve their outcomes. It is designed to aid communication between members of the Neonatal Intensive Care Unit (...

Transitioning Newborns From NICU to Home: A Resource Toolkit 01/24/14

This toolkit for hospitals provides information and resources to improve safety when newborns transition home from the neonatal intensive care unit (NICU). Through a Health Coach Program, the toolkit offers coaches, parents, and families...

Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS) Toolkit 12/16/13

The goal of MARQUIS (Multi-Center Medication Reconciliation Quality Improvement Study) is to develop better ways for medications to be prescribed, documented, and reconciled accurately and safely at times of care transitions when patients enter...

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