Physician Practices Use Software-Facilitated System to Complete Medicare Annual Wellness Visit, Improving Preventive Care and Generating High Satisfaction
Primary care practices use a software-facilitated process to proactively schedule and efficiently complete required components of Medicare’s Annual Wellness Visit and to identify and address care gaps, leading to improvements in the provision of preventive services and high physician and patient satisfaction.
Primary Care Managers Supported by Information Technology Systems Improve Outcomes, Reduce Costs For Patients With Complex Conditions
The Care Management Plus program combines the care coordination services of a care manager with robust electronic tracking and reminder systems to deliver comprehensive medical care to seniors with multiple chronic illnesses in primary care clinics.
Nurse Case Managers Offer Low-Resource Transitional Care Services, Reducing Readmissions for At-Risk, Community-Dwelling Veterans in Remote Areas
Nurse case managers at a Veterans Affairs hospital provide inhospital and post-discharge, telephone-based support to at-risk, community-dwelling patients and their caregivers, leading to better care transitions, fewer readmissions, and substantial cost savings.
Outreach Workers Connect Low-Income Individuals Living in Rural Areas to Home- and Community-Based Services, Reducing Costs and Nursing Home Placements
Community outreach workers identify residents at risk of nursing home placement and arrange for them to receive appropriate home- and community-based services, leading to fewer nursing home placements and significant cost savings.
Discharge Education Program Increases Patient Understanding of Treatment and Followup Care
The Patient Safe-D(ischarge) program uses standardized tools to educate patients about their discharge needs, assess their understanding of those needs, and improve medication reconciliation at admission and discharge.
Try This: Best Practices in Nursing Care to Older Adults
Try This is a series of assessment tools where each issue focuses on a topic specific to the older adult population. The content is directed to orient and encourage all nurses to understand the special needs of older adults and utilize the highest standards of practice in caring for the elderly.
Develop Your "Hospital At Home" Program
"Hospital At Home" is an innovative health care model that can provide hospital-level care in a patient’s home as a full substitute for acute hospital care until the patient is ready for discharge to their primary care physician. The Web site contains information and tools for organizations that are considering starting their own program.
Health Care Leader Action Guide to Reduce Avoidable Readmissions
This guide for hospital leaders and administrators provides strategies to assess, prioritize, implement, and monitor efforts to reduce avoidable readmissions.
Virtual Integrated Practice (VIP) Toolkit
The Virtual Integrated Practice (VIP) toolkit is part of the VIP program, which is designed to develop effective team building and ongoing collaboration among health care providers who do not work together in practice in the same locations or even organizations. It replaces the logistical obstacles of having clinicians meet in person to discuss patient cases with a system of communicating and meeting "virtually" using an appropriate variety of readily available technologies.
BOOSTing (Better Outcomes for Older adults through Safe Transitions) Care Transitions Resource Room
The BOOSTing (Better Outcomes for Older adults through Safe Transitions) Care Transitions Resource Room provides a wealth of materials to help hospitals optimize the discharge process.