Discharge planning

Innovations

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...

Hospital Gain-Sharing Program Offers Incentives to Physicians Based on Their Efficiency, Producing Significant Cost Savings Without Decline in Quality 03/17/14

In a 3-year pilot demonstration program with the Centers for Medicare & Medicaid Services, 12 New Jersey hospitals known as the New Jersey Care Integration Consortium participated in a...

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...

Statewide Ban on Ambulance Diversions Reduces Ambulance Turnaround Time and Emergency Department Length of Stay for Patients Admitted to the Hospital 01/14/14

In 2009, the Massachusetts Department of Public Health became the first State to ban ambulance diversions—a practice in which a crowded emergency department temporarily stops accepting patients...

QualityTools

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...

Guide to Patient and Family Engagement in Hospital Quality and Safety 07/11/13

The Guide to Patient and Family Engagement in Hospital Quality and Safety is a tested, evidence-based resource to help hospitals work as partners with patients and families to improve quality and safety. It provides four evidence-based...

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