Oct 172011

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 Care Model, Care Transitions, Joanne Lynn, Advanced Practice Nurses

Oct 102011

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, and the Care Transitions Intervention developed and tested by Dr. Eric Coleman at the University of Colorado.

Oct 032011

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 transition, to know what is going on, what to expect and how to recognize when things are falling apart; and ensuring good information flow among all settings and with patients and caregivers.



Key Words: Care transitions, quality improvement, process standardization, patient activation, information flow

Sep 282011

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 Hebrew SeniorLife,  an integrated eight-site system of health care, housing, research, and teaching based in Boston. The Practice Change Fellows Program [now the Practice Change Leaders for Aging and Health Program] is a two-year award that enables clinicians to work on projects to improve care of older adults, supporting them as they develop leadership skills and content expertise.

According to AHRQ, Berkowitz developed a program that featured: standardized assessment at admission to identify patients with multiple prior hospitalizations, palliative care consults and care plans for those who had had three or more hospitalizations in the previous six months, and a multidisciplinary staff conference to examine the root causes of inpatient readmissions when they occurred. As a result, inpatient readmissions decreased by 20%, from 16.5% before implementation to 13.3% after it.

Developing the project required that Berkowitz obtain approval from Hebrew SeniorLife leaders, form and advisory committee, develop the standardized admissions template, and introduce program and multidisciplinary conferences.  Learn more about the work at


Key Words: readmissions, palliative care consults, skilled nursing facility, care transitions

Sep 262011

AHRQ Innovators Exchange features information and a video about a pilot study to improve care for low-income elderly patients with chronic illnesses.


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% rated their experience as good or excellent one year after participation. The program led to cost savings of approximately $600 to $1000 per patient per month as a result of decreased hospitalizations. Summa Health is now conducting a three-year randomized controlled trial to confirm these results.

Summa Health System developed a program called the Frail Elders Care Management Program. The project involved interdisciplinary teams that provide integrated medical and social care management to low-income elderly in-patients who have chronic illnesses. The program aimed to ease the transition from hospital to home, provide preventive care, identify new and emerging problems, reduce readmissions, and prevent functional decline. Most participants were over the age of 65, had several chronic conditions and impaired activities of daily living, and had one or more problems that required an intervention. For example, nearly 40% of patients took more than 10 prescriptions, and nearly 50% had experienced one or more falls.

The project featured an interdisciplinary team whose members included a geriatrician, an advanced practice nurse, a registered nurse care manager, a social worker, and a geriatric pharmacist. Other clinicians were called on as needed. Primary care physicians, who then received a one-time fee, participated in a consultation with the nurse care manager. Over the course of three years, the Frail Elders Care Management Program served 1,272 patients. Based on promising preliminary results, AHRQ funded a three-year randomized controlled trial.

Key Words: frail elders, care transitions, quality improvement, interdisciplinary teams

Sep 262011

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 in their own system before they can engineer effective solutions. You can also learn more about how to work locally by reading the Get Started guide, which you can find here:


Key words: Care transitions, quality improvement, community-based organizations

Sep 252011

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 winning developer. Software developers have until November 16, 2011, to sign up for the challenge. I am one of the judges for the competition, and I hope we will have lots of useful applications to evaluate. For full details, visit the competition website, ”Ensuring Safe Transitions from Hospital to Home Challenge”, at http://legacy.health2con.com/devchallenge/files/iBlueBotton-Slides.pdf.

This tech challenge is sponsored by the Office of the National Coordinator for Health Information Technology (ONC-HIT) in collaboration with the Partnership for Patients. The Partnership for Patients is a new nationwide public-private partnership launched by Secretary of Health and Human Services Kathleen Sebelius to tackle all forms of harm to patients. Its aims include a 20% reduction in readmissions over a three year period and a 40% reduction in preventable hospital-acquired conditions.

Nearly one in five patients discharged from a hospital will be readmitted within 30 days. A large proportion of readmissions can be prevented by improving communications and coordinating care before and after discharge. The Centers for Medicare and Medicaid Services (CMS) provides a discharge checklist to help patients and their caregivers prepare to leave a hospital, nursing home, or other care setting. Research has shown that empowering patients and caregivers with information and tools to manage the next steps in their care more confidently is a very effective way to reduce errors, decrease complications, and prevent a return visit to the hospital.

The ideal application for this tech challenge will:

  • Incorporate the content of the CMS Discharge Checklist
  • Help patients and caregivers access the information and materials needed to answer the checklist’s questions about their condition, their medications and medical equipment, and their post-discharge plans
  • Share this information with doctors, pharmacists, nurses and other professionals in their next care setting (e.g., home, nursing home, hospice)
  • Identify community-based organizations or others who can provide valuable assistance
  • Leverage and extend NwHIN standards and services including, but not limited to, transport (Direct, web services), content (Transitions of Care, CCD/CCR), and standardized vocabularies
Sep 192011

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 get started.

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

Sep 082011

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 transitions, how to get started, and where to find ideas, resources, and guidance.