What kinds of changes are needed to improve care transitions, and thereby improve patient care and experience? It is a complex issue, and requires hard work. Building the will to face and fix these problems is essential to creating a better health care system. Dr. Joanne Lynn describes how individuals and organizations can get motivated—and […]
Transitions between care settings are fraught with errors that can lead to unnecessary suffering for patients and families, frustration for clinicians, and avoidable expenses for providers. Organizations nationwide need to pull together to create a seamless care system for patients living with multiple chronic conditions. Dr. Joanne Lynn explains why the issue of care transitions […]
Meet Dr. Joanne Lynn as she describes work being done by the Altarum Institute Center for Elder Care and Advanced Illness to improve care transitions. This is the introduction to a 12-part series that will be released over the next several weeks. Stay tuned for more, with information on why it’s important to address care […]
by Dr. Joanne Lynn A colleague asks if it makes sense, when engaging in care transitions work, to begin with a disease focus, specifically in congestive heart failure. Innovators do need to start their efforts somewhere, and doing so in areas in which there is a strong will and the perception of a workable plan […]
A colleague asked an important question: Which tools are best for reviewing causes of readmissions? Two examples, from Georgia and New Jersey, are attached to this posting. Georgia’s form requires starting from a patient/family interview review, and does not pull much from the record of the hospitalization. New Jersey’s form starts from the other direction […]
As a frontline hospital or nursing home professional, you may be feeling increasingly frustrated with the lack of support, community follow-up and caregiver training for your vulnerable patients and residents. Despite your hard work these complicating factors are likely to send your patient or resident back to the hospital. Your administrators may have suggested to […]
The Long-Term Quality Alliance (LTQA) was formed to respond to the increasing demand for long-term services and support and the expanding field of providers who are delivering that care. The Alliance is working to make sure that the 11 million people who need long-term services and supports in the United States receive the highest quality […]
Community coalitions can be an effective way to engage diverse stakeholders in achieving common goals. Establishing such coalitions to address problems in care transitions is likely to be an essential tool for ensuring that such transitions become routinely good. Shortcomings in transitions today reflect larger, systemic problems that can best be addressed by community organizations […]
Joanne Lynn and I have collaborated on a paper covering applications of Elinor Ostrom’s model of voluntary social arrangements to the challenges of Health Care. With this post we provide links where you can download our paper if you wish to read it in full. Elinor Ostrom’s work to describe long-lived voluntary social arrangements that […]
Since many potential applicants are now figuring out how to use the financial template for Community-Based Care Transitions Program (CCTP) funding (as mentioned in our previous blog at: https://medicaring.org/2011/07/08/community-based-care-transitions-program-%e2%80%93-section-3026-funding/), here are some suggestions on mapping out a successful care transition model utilizing blended rate. First, realize that all payments are to the Community-Based Organization, and […]