by Larry Beresford The Hospital Association of Southern California, which convened a Palliative Care Committee to provide mutual support among its members working on palliative care initiatives, recently changed the committee’s name to the Care Transitions Committee, reflecting the affinities between these two major quality currents within America’s hospitals. But as the cover story in […]
Dr. Joanne Lynn describes Project RED (Re-Engineered Discharge), a program developed by Dr. Brian Jack and his colleagues at Boston University. It is designed to help hospitals to re-engineer their discharge processes, and offers some free online materials and guidance, as well as IT-enabled patient transition aids. You can read more about the details of […]
In a factsheet from AARP’s Public Policy Institute, Lynn Feinberg and Allison M. Reamy detail how provisions of the Affordable Care Act (ACA) will lead to better recognition of and support for family or informal caregivers. An estimated 40 million Americans are family caregivers, and provide everything from help with transportation to assistance with daily […]
Advanced practice nurses can be very effective in helping to bridge transitions from hospital to home. Dr. Joanne Lynn describes the Transitional Care Model, developed and tested by Dr. Mary Naylor and her colleagues at the University of Pennsylvania. You can learn more about TCM from: https://www.nursing.upenn.edu/ncth/transitional-care-model/about-the-tcm/, and by watching the video below. Keywords: Transitional […]
Patient activation—teaching patients to take charge of their care—is an essential element of improving care transitions. Patients need to know what to expect, how to recognize when things are going wrong, and what to do about it. Dr. Joanne Lynn talks about the Patient Activation Measure, one way to gauge patient engagement in their care, […]
In today’s installment of the video series on improving care transitions, Dr. Joanne Lynn describes three crticial elements for ensuring smoother transitions. These are standardizing the process (in part by mapping what you do now and understanding how the current system works–or does not); activating and mobilizing patients and caregivers to take charge of the […]
A three-part protocol, involving standardized assessment, palliative care consultations, and root cause analysis led to a 20% reduction in hospital readmissions for elderly skilled nursing facility residents, according to the AHRQ Health Care Innovations Exchange. Led by Dr. Randi Berkowitz, a Practice Change Fellow, the initiative focused on reducing the risk of hospital readmissions at […]
AHRQ Innovators Exchange features information and a video about a pilot study to improve care for low-income elderly patients with chronic illnesses. https://innovations.ahrq.gov/videos Conducted by Ohio-based Summa Care under the leadership of Practice Change Fellows and Advisory Board Member Kyle Allen, DO, AGSF, the project reports that 70% of participants reported improved health, and 93% […]
Fixing what’s wrong with care transitions will require changes in how systems work, both internally and with other systems. In this video, Dr. Joanne Lynn explains the importance of understanding your own health care system in order to fix problems in care transitions. Community and medical care providers need to work together to understand drivers […]
A technology challenge is looking for innovative ways to improve the quality of care transitions, reduce preventable hospital readmissions, and improve patient safety. Tech challenges are a popular tool in the technology community to encourage innovative development among software developers. In this case, the first prize is $25,000 (plus tons of free publicity) for the […]