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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.
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.
Emergency Department–Based Asthma Clinic Improves Self-Management Behaviors and Reduces Acute Episodes for Low-Income, Inner-City Children and Teenagers 9/10/2014
An asthma clinic located within the emergency department of a children’s hospital provides education, nonurgent medical care, referrals to primary care providers, and followup support to low-income, inner-city children and teenagers, leading to improvements in self-management behaviors, fewer acute asthma episodes, and better quality of life.
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 Asthma Educators Train Patients, Providers, and Community Members on Optimal Care, Leading to Fewer Admissions, Emergency Department Visits, and Missed Work Days 8/27/2014
Asthma educators help patients, providers, school nurses, childcare providers, pharmacists, and others in the community achieve optimal asthma treatment, leading to fewer hospitalizations, emergency department visits, and missed work days.
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QualityTools
Discharge Risk Assessment 7/30/2014
This risk assessment tool helps hospital discharge planners fully understand patient needs, thereby avoiding readmissions.
Improving Treatment Decisions for Patients With Community-Acquired Pneumonia 12/18/2013
This report describes two tools developed by the Agency for Healthcare Research and Quality (AHRQ) funded research that help assess the need for hospitalization of patients with community-acquired pneumonia (CAP) and determine the medical stability of patients prior to discharge.
STate Action on Avoidable Rehospitalizations (STAAR) Materials 12/18/2013
The STate Action on Avoidable Rehospitalizations (STAAR) Initiative of the Institute for Healthcare Improvement and The Commonwealth Fund aims to reduce avoidable rehospitalizations. This Web site features guides, presentations, and other tools related to reducing readmissions.
Managing Drug-Seeking Behaviors & Super Users in the Emergency Department 10/23/2013
This guide for emergency department (ED) physicians, nurses, and caregivers includes information and tools for providing pain management care to drug "super users" in the ED.
Medical Respite Tool Kit 10/23/2013
The purpose of the Medical Respite Tool Kit is to provide information and tools to help organizations and advocates plan, develop, and sustain medical respite programs. This tool organizes existing resources developed by the National Health Care for the Homeless Council and other medical respite providers while incorporating new and practical tools.

Last updated: September 10, 2014.