Sep 122011

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 is paramount in endeavors to improve care of frail elders, and others living with advanced chronic conditions. This is the first of a 12-part video “how-to” series in which Dr. Lynn provides an overview of the issues, describes quality improvement efforts underway, and gives tips for clinicians and communities ready to get started in their own settings.

Key words: care transitions, frail elders, quality improvement, Joanne Lynn

May 172011

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.

You can download a PowerPoint presentation by clicking the following link:

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