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Innovations
Church-Health System Partnership Facilitates Transitions From Hospital to Home for Urban, Low-Income African Americans, Reducing Mortality, Utilization, and Costs 9/10/2014
A partnership between a large health system and 512 churches supports the transition from the hospital back into the community, leading to lower mortality, health care utilization, and health care costs and to higher satisfaction with hospital care.
Policy Inclusive Design Process and Extensive Promotion and Support Generate Widespread Use of Health Information Exchange, Leading to Improvements in Health Outcomes 9/10/2014
Use of an inclusive design process and the investment of significant time and resources in promoting and supporting use of a health information exchange generates widespread participation by providers, which in turn leads to more patients having an electronic health record, better management of high cholesterol, and increased provision of tobacco cessation counseling and screening for depression and breast cancer.
Updated Transition Home Program Reduces Readmissions for Heart Failure Patients 9/10/2014
The Transition Home program incorporates a number of components to ensure patients a safe transition to home or another health care setting, leading to fewer readmissions.
Community-Based Clinic Enhances Access to Medical Care and Reduces Emergency Department Visits for Chronically Ill Recently Released Prisoners 8/27/2014
Community-based clinic enhances access to medical care and reduces emergency department visits for chronically ill individuals who have recently been released from prison.
Hospital-Based Palliative Care Program Adds Comprehensive Outpatient Services, Leading to Better Access and High Patient and Provider Satisfaction 8/27/2014
A medical center added outpatient palliative services, including symptom management and holistic emotional, psychosocial, and spiritual care, to its comprehensive inpatient palliative care services, leading to improved access and high levels of patient, family, and provider satisfaction.
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QualityTools
Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals 8/27/2014
This guide provides recommendations to help hospitals address unique patient needs, meet patient-centered communication standards, and comply with related Joint Commission requirements.
IMPaCT™ Model Tool Kit 8/27/2014
The IMPaCT™ model is an evidence-based system for community health worker recruitment, training, and care. This toolkit is designed to help other organizations adapt and implement this model. 
Envisioning My Future: A Young Person's Guide to Health Care Transition 8/13/2014
This guide, written for youth with special health care needs, helps them prepare for their transition from pediatric health care or service to adult care or service.
Discharge Risk Assessment 7/30/2014
This risk assessment tool helps hospital discharge planners fully understand patient needs, thereby avoiding readmissions.
Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS) Toolkit 6/18/2014
The goal of MARQUIS (Multi-Center Medication Reconciliation Quality Improvement Study) is to develop better ways for medications to be prescribed, documented, and reconciled accurately and safely at times of care transitions when patients enter and leave the hospital.

Last updated: September 10, 2014.