Church-Health System Partnership Facilitates Transitions From Hospital to Home for Urban, Low-Income African Americans, Reducing Mortality, Utilization, and Costs
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.
Transition Home Program Reduces Readmissions for Heart Failure Patients
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.
Primary Care Physician Communication With Patients at or Soon After Discharge Significantly Reduces Medication Discrepancies
After being briefed by hospitalists, primary care physicians meet or talk by phone with patients who have complex medication regimens at or soon after discharge, leading to a significant reduction in medication discrepancies.
Community Health Workers Embedded in Inpatient and Outpatient Clinical Teams Enhance Access to Primary Care and Improve Health Outcomes for Low-Income Patients
Community health workers embedded in clinical teams in medical offices and hospitals support low-income patients in setting and achieving health-related goals and accessing needed medical and community-based services, leading to better communication and access to postdischarge primary care, increased patient activation, fewer readmissions and depression-related symptoms, and positive feedback from patients.
Hospital Gain-Sharing Program Offers Incentives to Physicians Based on Their Efficiency, Producing Significant Cost Savings Without Decline in Quality
A group of 12 New Jersey hospitals offered upside incentives to individual physicians based on their performance on various efficiency metrics, leading to significant cost savings without negatively affecting quality of care.
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Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals
This guide provides recommendations to help hospitals address unique patient needs, meet patient-centered communication standards, and comply with related Joint Commission requirements.
Discharge Risk Assessment
This risk assessment tool helps hospital discharge planners fully understand patient needs, thereby avoiding readmissions.
Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS) Toolkit
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.
Transitioning Newborns From NICU to Home: A Resource Toolkit
This toolkit for hospitals provides information and resources to improve safety when newborns transition home from the neonatal intensive care unit.
Toolkit for the Follow-Up Care of the Premature Infant
This toolkit for health care professionals provides information and resources to help facilitate the care of premature infants and improve their outcomes.