Postdischarge Care Management Integrates Medical and Psychosocial Care of Low-Income Elderly Patients
An interdisciplinary care management program that integrates medical and social care for low-income elderly patients with chronic illnesses reduces care costs and improves self-reported health status.
Clinics and Hospitals Use Trained, Certified Community Members To Screen and Support Primary Care and Postdischarge Patients, Reducing Physician Visits and Costs
Specially trained and certified lay workers known as "Grand-Aides" use illness-specific protocols to ensure that patients receive appropriate treatment in primary care settings and to ease the transition from hospital to home after discharge. The primary care-based program has reduced unnecessary visits and demonstrated the potential to reduce costs. Early data from one hospital program show significant reductions in readmissions.
Inpatient Education and Counseling and Postdischarge Followup Lead to Improved Health for Patients With Diabetes and/or Obesity
The Hospital of the University of Pennsylvania's Transitions in Care program bridges the gap between hospital discharge and outpatient followup care for patients who are obese and/or have diabetes, leading to improvements in physical health status.
Collaborative Medication Reconciliation Significantly Reduces Errors and Readmissions in Patients Discharged to Nursing Homes
A collaborative medication review process involving physicians, nurses, and pharmacists virtually eliminates medication errors and significantly reduces readmissions in patients discharged to a nursing home.
Protocols, 24-Hour Neurologist Access, and Ongoing Training Lead to More Patients Receiving Timely Stroke Diagnosis and Treatment
A comprehensive initiative to improve stroke care features protocols to facilitate faster evaluation and diagnosis, quick administration of tissue plasminogen activator when indicated, 24-hour access to a neurologist, enhanced discharge planning, improved documentation and data collection, continuous staff training, and community outreach, leading to more timely administration of appropriate diagnostic tests and treatment and to many more eligible patients receiving tissue plasminogen activator.
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Taking Charge of Your Healthcare: Your Path to Being an Empowered Patient
Health care providers can use this toolkit during hospital discharge to help patients leave the hospital with confidence. It includes the tools and information patients need to make a smooth transition to their next destination.
Taking Care of Myself: A Guide for When I Leave the Hospital
Taking Care of Myself: A Guide for When I Leave the Hospital is a guide that providers can use to give patients the information they need to care for themselves when they leave the hospital.
Coordinated-Transitional Care Toolkit
The goal of this toolkit is to help hospital systems that serve populations with high rates of patient dispersion, cognitive impairment, and vulnerability improve care coordination and postdischarge outcomes such as reduced medication discrepancies.
Guide to Patient and Family Engagement in Hospital Quality and Safety
The Guide to Patient and Family Engagement in Hospital Quality and Safety is a tested, evidence-based resource to help hospitals work as partners with patients and families to improve quality and safety.
Reengineered Discharge Toolkit
This toolkit was developed to facilitate the Project RED intervention.