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Innovations
Case Management and Home Assessments Reduce Asthma-Related Admissions, Emergency Visits, and Missed School Days in Diverse Urban Children 4/23/2014
Case management combined with in-home environmental assessment and remediation of environmental triggers reduce asthma-related hospitalizations, emergency department visits, missed school days, and missed parent work days in diverse, low-income urban children with asthma.
Day Hospital Reduces Inpatient Length of Stay and Emergency Department Visits for Patients With Sickle Cell Anemia 4/23/2014
A Sickle Cell Day Hospital provides an alternative to inpatient care for patients with sickle cell anemia, with the goal of managing their pain and keeping them out of the hospital, resulting in lower inpatient lengths of stay and emergency department utilization.
Archived Health Coach Program in a Medical Group Improves Self-Care and Decreases Readmissions for High-Risk, Chronically Ill Patients 4/23/2014
Dartmouth-Hitchcock Clinic assigned health coaches to high-risk chronic disease patients to provide instruction regarding health care needs over the phone, during office visits, and in group classes; the program reduced readmission rates and costs among elderly patients.
Intensive Case Management Aids Parents With Co-Occurring Disorders and Their Children, Leading to Healthy Families 4/23/2014
Ongoing case management, education, and peer support to low-income parents struggling with mental health and substance abuse disorders focuses on reducing the stigma associated with illness, increasing positive family interaction, and identifying and addressing cognitive and behavioral problems in children. Evidence suggests the program leads to less mental health–related stigma and stress, improved parenting skills and social support networks, few psychiatric hospitalizations, enhanced access to needed services for children, and many lasting family reunifications.
Managed Care Organization and Visiting Nurse Association Offer Standardized Education to Elderly Heart Failure Patients, Improving Self-Management and Reducing Readmissions 4/23/2014
Kaiser Permanente Colorado and the Visiting Nurse Association in Denver jointly offer intense, consistent education to elderly heart failure patients discharged from the hospital in need of home-based skilled nursing care, leading to improved knowledge and self-management skills and fewer readmissions.
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QualityTools
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.
Coordinated-Transitional Care Toolkit 7/31/2013
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.

Last updated: April 23, 2014.