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Visiting Nurse Service of New York's Choice Health Plans: Continuous Care Management for Dually Eligible Medicare and Medicaid Beneficiaries
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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
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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.
An Early Look at a Four-State Initiative to Reduce Avoidable Hospital Readmissions
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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.
Recasting Readmissions by Placing the Hospital Role in Community Context
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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.
STAAR Issue Brief: The Effect of Medicare Readmissions Penalties on Hospitals’ Efforts to Reduce Readmissions
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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.
Enhancing the Effectiveness Effectiveness of Follow-Up Phone Calls to Improve Transitions in Care: Three Decision Points
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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.
Effective Interventions to Reduce Rehospitalizations: A Compendium of 15 Promising Interventions
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This document highlights the range of effective programs underway to reduce avoidable rehospitalizations across the US.
Patient First: Efficient Patient Flow Management Impact on the ED
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Memorial Regional Hospital (Hollywood, Florida, USA) improves care and service in the adult emergency department by focusing on key operational, clinical, and service improvement strategies.
WIHI: Mobilizing Skilled Nursing Facilities to Reduce Avoidable Rehospitalizations
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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.
WIHI: Breaking the Cycle of Readmissions
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May 7, 2009 | For a significant number of patients, readmission to the hospital happens all too frequently — for costly reasons that could be better anticipated and avoided. There are ways to reduce readmissions, even in a notoriously fragmented health care system.
WIHI: Reducing Readmissions, Restoring Revenues: Making Good Care Count
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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.
WIHI: The Ground Game of the Partnership for Patients
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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.
WIHI: Reality Knocks with Reducing (Hospital) Readmissions
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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.
How-to Guide: Improved Care for Patients with Congestive Heart Failure — Rural Hospitals Supplement
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The goal of this How-to Guide, which has been tailored specifically for rural hospitals, is to significantly improve care and reduce readmissions for patients with congestive heart failure by reliably implementing the recommneded components of care.
How-to Guide: Improved Care for Patients with Congestive Heart Failure
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The goal of this How-to Guide is to significantly improve care and reduce readmissions for patients with congestive heart failure by reliably implementing the recommended components of care.
Getting Started Guide: Improving Care for Patients with Heart Failure — Focus on Ambulatory Care
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This Guide builds on the promising work in the hospital setting by applying known best practices to the outpatient care of individuals with heart failure, and by highlighting the high-leverage opportunities for improvement in office practices.
How-to Guide: Improving Transitions from the Hospital to Community Settings to Reduce Avoidable Rehospitalizations
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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.
How-to Guide: Improving Transitions from the Hospital to Home Health Care to Reduce Avoidable Rehospitalizations
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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 the Clinical Office Practice to Reduce Avoidable Rehospitalizations
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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.
How-to Guide: Improving Transitions from the Hospital to Skilled Nursing Facilities to Reduce Avoidable Rehospitalizations
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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.
St. Luke’s Hospital: Where Patients’ Home Care Needs Are Anticipated at Discharge
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By providing self-management support for patients at home, St. Luke’s Hospital in Cedar Rapids, Iowa, part of the Iowa Health System, is reducing its rate of readmissions for heart failure patients.
Improving Heart Failure Care Through Education
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At Advocate Health Care, based in Oak Brook, Illinois (USA), the Heart Failure team recognized that teaching patients how to self manage this chronic illness is vital to improved quality of life and can have a significant impact on readmission rates.
Reducing Readmissions for Heart Failure Patients: Hackensack University Medical Center
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Hackensack University Medical Center (Hackensack, New Jersey, USA) has dramatically reduced heart failure readmission by implementing telephone follow-up with patients.
Targeting Patient Transitions to Reduce Readmissions
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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.
SMART Discharge Protocol
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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.
  
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