By Les Morgan The following reports were produced as deliverables for our project “Aggregating Care Plans to Manage Supportive Care Services for Elders” (Joanne Lynn, M.D., Principal Investigator).This project is funded by the Gordon and Betty Moore Foundation through Grant GBMF5662 to Altarum Institute. Dr. Lynn will provide a more detailed report on the project
Tag: discharge planning
By Anne Montgomery and Leslie Fried of the National Council on Aging One of the hallmarks of the 21st century—increased longevity of the population—will increasingly drive federal, state, and local health care programs to focus on optimizing coordination of services across a range of medical care and community services providers. Discharge planning will play a
By Dr. Kyle Allen and Susan Hazelett The Summa Health System/Area Agency on Aging, 10B/Geriatric Evaluation Project(SAGE) is a collaboration between an integrated health system and the local Area Agency on Aging which was begun in 1995. SAGE provided the organizational structure to develop the resources and processes needed to effectively integrate geriatric medical services
Older residents (with fee-for-service Medicare) of a four-county region around Rochester, New York, are likely to benefit from the innovative programs being launched by a community-based care transitions project (CCTP) in that region. The “Community-wide Care Transitions Intervention” is anchored by Lifespan of Greater Rochester, a non-profit organization funded mostly by the Administration on Aging.
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 (http://www.nmh.org/nm/for-physicians-match) 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
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
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 its website: http://www.transitionalcare.info/, and by watching the video below.
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