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WIHI: Lowering Readmissions, Reducing Disparities
October 25, 2018 | Initiatives to reduce avoidable readmissions are the norm in US health systems today. What happens when hospitals and health systems look beyond to the non-clinical issues upstream that have a big impact on rehospitalizations?
Visiting Nurse Service of New York's Choice Health Plans: Continuous Care Management for Dually Eligible Medicare and Medicaid Beneficiaries
This case study describes how a large nonprofit home health care provider created health plans to serve the dually eligible Medicare and Medicaid population, and how its customized care management approach led to reductions in hospitalizations and readmissions.
Gaining Ground: Care Management Programs to Reduce Hospital Admissions and Readmissions Among Chronically Ill and Vulnerable Patients
Preventable hospital admissions and readmissions are indicators of health system fragmentation associated with suboptimal patient outcomes and avoidable costs of care. This synthesis report looks at three case studies that illustrate the potential of care management programs to address this problem by improving care coordination and transitions among high-risk patients.
WIHI: Mobilizing Skilled Nursing Facilities to Reduce Avoidable Rehospitalizations
February 27, 2014 | This WIHI looks at new developments in better coordination and communication between SNFs, local hospitals, and various community stakeholders, to reduce unnecessary transfers of patients to acute care settings.
SMART Discharge Protocol
The SMART Discharge Protocol (Signs, Medications, Appointments, Results, and Talk with me) was developed to improve care for patients and families and to improve the discharge process. The tools include the SMART Discharge Checklist for patients and families, FAQs for health care staff and clinicians about implementing the SMART Discharge Protocol, a presentation, and a self-learning packet.
Hospital Readmissions: Measuring for Improvement, Accountability, and Patients
The Commonwealth Fund and the Institute for Healthcare Improvement convened 15 experts in May 2013 to help address the controversy over the measurement of hospital readmissions. Experts agreed that Medicare should, through payment and other means, be encouraging greater coordination of care, improvement in care transitions, and mitigation of risks that leave patients vulnerable to readmission.
WIHI: The Ground Game of the Partnership for Patients
June 27, 2013 | Two Partnership for Patients' Hospital Engagement Networks — Ascension Health and Joint Commission Resources, Inc. — discuss their work to embed patient engagement into every hospital’s safety work, and to reduce hospital-acquired conditions and readmissions.
Enhancing the Effectiveness Effectiveness of Follow-Up Phone Calls to Improve Transitions in Care: Three Decision Points
This study used a nonsystematic review of the literature focused on the use of telephone follow-up to improve postdischarge processes and reduce avoidable readmissions, and examined use of such calls among organizations participating in the STate Action on Avoidable Rehospitalizations (STAAR) initiative.
STAAR Issue Brief: The Effect of Medicare Readmissions Penalties on Hospitals’ Efforts to Reduce Readmissions
To understand the impact of the Medicare financial penalties for hospitals that have higher than expected rates of 30-day readmissions for select conditions, this Issue Brief synthesizes perspectives from leaders of state hospital associations, quality improvement organizations, and hospitals representing a range of performance and experiences in readmissions and their reduction.
Targeting Patient Transitions to Reduce Readmissions
The transition that takes a patient from the hospital to their home or another care setting marks a pivotal care moment. Zeroing in on what happens during this critical juncture, with the support of IHI’s STAAR initiative, has helped the Ohio Hospital Association make significant progress in its aim to reduce hospital readmissions by 20 percent within two years.
Recasting Readmissions by Placing the Hospital Role in Community Context
The authors suggest that it is advantageous to view readmissions within a broader systems and community context that effectively engages all stakeholders to cooperatively improve outcomes.
Reducing Avoidable Rehospitalizations: Getting Started with Creating an Ideal Transition from Hospital to Home
This video will review the steps to getting started on creating an ideal transition home for patients and families being discharged from the hospital, as part of overall efforts to reduce avoidable rehospitalizations.
IHI's Approach to Reducing Avoidable Rehospitalizations
This video will make the case for reducing avoidable rehospitalizations by creating a more patient-centered ideal transition home.
WIHI: Reality Knocks with Reducing (Hospital) Readmissions
November 15, 2012 | This WIHI convenes important leaders and thinkers to talk about promising ideas and strategies for reducing avoidable hospital readmissions and improving care coordination.
Reducing Hospital Readmissions
Reducing avoidable hospital readmissions takes collaboration among a full range of health care settings and stakeholders beyond the "hospital walls," and requires understanding and attending to the experiences of patients over time, across settings.
Readmissions Diagnostic Worksheet
This diagnostic tool helps hospitals perform an in-depth review of the last five rehospitalizations to identify opportunities for improvement.
How-to Guide: Improving Transitions from the Hospital to the Clinical Office Practice to Reduce Avoidable Rehospitalizations
This How-to Guide is designed to support office practice-based teams and their community partners in codesigning and reliably implementing improved care processes to ensure that patients who have been discharged from the hospital have an ideal transition back to the care team in the office practice, with the related goal of reducing avoidable readmissions.
Effective Interventions to Reduce Rehospitalizations: A Compendium of 15 Promising Interventions
This document highlights the range of effective programs underway to reduce avoidable rehospitalizations across the US.
Effective Interventions to Reduce Rehospitalizations: A Survey of the Published Evidence
This survey of the published literature regarding the effective interventions to reduce avoidable rehospitalizations revealed that the current body of published interventions fall into four broad categories.
An Early Look at a Four-State Initiative to Reduce Avoidable Hospital Readmissions
The STate Action on Avoidable Rehospitalizations initiative (STAAR) has been successful in aligning numerous complementary initiatives within a state, developing statewide rehospitalization data reports, and mobilizing a sizable number of hospitals to work on reducing rehospitalizations.
Reduced readmissions: Reform's low-hanging fruit
Based on experience in the STAAR (STate Action on Avoidable Rehospitalizations) initiative, the Institute for Healthcare Improvement recommends seven concepts as key framing opportunities for health care executives.
WIHI: Reducing Readmissions, Restoring Revenues: Making Good Care Count
October 7, 2010 | This WIHI discusses why it’s critically important to make the financial impact of reducing readmissions a living, breathing, part of your quality agenda. Also discussed is the STAAR initiative, which is working with a courageous group of hospitals that are learning how to analyze their admissions (and readmissions) patterns with some new eyes and new thinking.
How-to Guide: Improving Transitions from the Hospital to Skilled Nursing Facilities to Reduce Avoidable Rehospitalizations
This How-to Guide supports teams in skilled nursing facilities (SNFs) and their community partners in codesigning and reliably implementing improved care processes to ensure that residents have a safe and effective transition into the SNF, with the related goal of reducing avoidable readmissions into the hospital.
How-to Guide: Improving Transitions from the Hospital to Home Health Care to Reduce Avoidable Rehospitalizations
This How-to Guide is designed to support home health care improvement teams and their hospital and community partners in creating an ideal reception into home health care in the first 48 hours after the patient is discharged from the hospital, a post-acute care setting, or a rehabilitation facility, with the related goal of reducing avoidable rehospitalizations.
How-to Guide: Improving Transitions from the Hospital to Community Settings to Reduce Avoidable Rehospitalizations
This How-to Guide is designed to support hospital-based teams and their community partners in codesigning and reliably implementing improved care processes to ensure that patients who have been discharged from the hospital have an ideal transition to the next setting of care, with the related goal of reducing avoidable readmissions.