Tag: hospital readmissions

From Hospital to Home: The Missing Element in 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

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The Evidence That the Readmissions Rate (Readmissions/Hospital Discharges) Is Malfunctioning as a Performance Measure

Dr. Joanne Lynn Portrait

By Joanne Lynn M.D. [Also see companion post by Stephen F. Jencks, M.D., M.P.H.] Care transitions improvement programs have been effective in helping the health care system both become more effective in serving people living with serious chronic conditions and reduce costs. However, the key metric used to measure performance is seriously malfunctioning in at

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JAMA Report Finds Community Collaboration Key to Reducing Hospitalizations and Rehospitalizations

By Dr. Joanne Lynn The latest issue of JAMA features our paper describing   an exciting and successful initiative from the Centers for Medicare and Medicaid Services (CMS) and fourteen of its quality improvement organizations (QIOs).  Grounded in quality improvement methodology—plan-do-study-act–this unusual project offers many insights for those aiming to reduce avoidable readmissions.  And its raises

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Readmissions Count: Should CMS Revise Its Calculations?

by Dr.  Joanne Lynn When community coalitions apply for funding from the Community-Based Care Transitions program of the Centers for Medicare and Medicaid (CMS), they have to show that they will reduce hospital readmissions by 20% and will save money for Medicare. Funding recipients will be held to those two outcomes in evaluating the contract.

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Reaching Rural Residents: Improving Care Transitions in Western New York State

The P2 Collaborative of Western New York [name was changed to Population Health Collaborative in 2017] represents a different spin on the Community-based Care Transitions Program (CCTP) model. It is unique in its focus on a very rural area of Western New York, and is unusual in that it is one of a few  community-based

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SAGE: Bridging the Divide between Acute Medical Care and Social Services in Northeast Ohio

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

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CMS Announced First Awards for CCTP Funding

CMS announced the first sites selected for the Community Based Care Transition Program. Please see the links below for the list of sites and an updated fact sheet. As noted above, we continue to accept applications and look forward to selecting additional sites in the near future. The following overview of the selected sites offers

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Room to Grow: Palliative Care’s Place in Care Transitions

 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

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Learning from Reviewing Readmissions: Tools You Can Use

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

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Better Care Transitions: Starting Points for Clinicians

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

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