by Carol Levine Carol Levine is director of the United Hospital Fund’s Families and Health Care Project, which coordinates the Next Step in Care campaign. Family caregivers often say that they feel invisible in hospitals and other health care settings. I know what they mean from my own 17 years’ experience caring for my late […]
Groups looking to improve their medication reconciliation process, a critical element of improved care transitions, will find how-to guidance in a just-released Agency for Healthcare Research and Quality toolkit, Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation (http://www.ahrq.gov/qual/match/match.pdf). Based on an online toolkit (https://www.ahrq.gov/patient-safety/resources/match/index.html) developed by Gary Noskin, M.D., and Kristine Gleason, […]
Patients just discharged from the hospital urgently need rapid follow-up in the community. Dr. Joanne Lynn describes the care coordination needed among patients, community providers, hospitals, and other settings, and what’s needed to make it work. Key words: rapid follow-up, care transitions, discharge planning, quality improvement, rehospitalization
The Southwest Ohio Care Transitions Collaborative, one of 7 sites chosen by the Centers for Medicare and Medicaid for the first cohort of 3026 funding, had lots going for it as it pulled together a broad-based community health coalition and implemented strategies to reduce avoidable readmissions for older adults. The program brought to its application […]
Hospice and palliative care can play a major role in improving care transitions for patients who have serious chronic conditions. Dr. Joanne Lynn explains how the hospice/palliative care model can improve patient care, offering 24/7 support, excellent symptom management, and wraparound services. People will need to realize what they’re up against, and turn to these […]
CMS announced the first sites selected for the Community Based Care Transition Program. Please see the links below for the list of sites and an updated fact sheet. As noted above, we continue to accept applications and look forward to selecting additional sites in the near future. The following overview of the selected sites offers […]
Under the 10th Statement of Work, QIOs nationwide will be launching exciting new programs to improve care transitions. This three-year endeavor builds on promising working undertaken by QIOs in 14 states. Dr. Joanne Lynn explains what’s coming and how to get involved. Key words: care transitions, QIOs, 10th SOW, 10th Statement of Work, quality improvement
The Centers for Medicare and Medicaid launched Community-Based Care Transitions Program, or CCTP, to reimburse the costs of coordinating care across settings. Dr. Joanne Lynn gives an overview of the program, and how it will work to engage community-based organizations engaged in improving care transitions. Key words: Care transitions, Community-based care transitions, Section 3026, quality […]
by Gloria N. Eldridge, PhD, MSc and Joanne Lynn, MD, MA, MS This posting first appeared on Altarum Institute’s Health Care Policy Forum, and is reprinted here with permission. Visit Altarum at www.altarum.org. The Obama Administration abandoned the Community Living Services and Supports (CLASS) Act last month. This public long-term care insurance program was slated […]
Community-based coalitions are critical to improving care transitions. To this end, people working throughout the community, in a variety of settings, really need to work to get to know one another, understand each other’s systems, and develop solutions that will translate into effective services for the community. Dr. Joanne Lynn describes a few steps to […]