Many improvement teams have real problems with measuring their progress – some never get around to measuring, and some never do anything else! This presentation was set for the communities funded under the Beacon initiatives that are working to bring information exchange to care transitions, but you’ll find the pointers applicable to any intervention that your community might try.
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caretransitionsmeasuresprimer (PowerPoint presentation)
Keywords: Beacon communities, care transitions, reasonable skeptic test, ten units of energy test, sure audience test, rehospitalization, best practices, Medicare, good care plans, near misses, targeting, nursing home residents, mentally ill, delirious, frail elderly, homeless, ESRD, ”revolving door” patients, case reviews, Care Transitions Measure, avoidable readmission, HCAHPS, discharge planning, denominator problems, numerator problems