Hospital-Based Social Workers Follow Up With Recently Discharged Older Adults to Resolve Transition Problems, Reducing Readmissions and Deaths
Hospital-based social workers support recently discharged older patients and their caregivers in resolving problems related to their transition back home, leading to enhanced patient and caregiver knowledge, better attendance at followup appointments, and fewer readmissions and deaths.
Culturally Competent Disease Management Improves Self-Monitoring and Blood Pressure Control in Hypertensive African Americans
A health plan–sponsored disease management program targeting African Americans combines home blood pressure monitoring with culturally competent education and counseling, leading to better self-monitoring and blood pressure control.
Statewide Initiative Focuses on Early Diagnosis, Care Team Activation, and Patient Transfer, Leading to More Timely Treatment for Heart Attack Patients
A statewide program in North Carolina promotes early initiation of evidence-based heart attack treatment through collaboration with trained paramedics and partnerships between and within hospitals, leading to earlier initiation of therapy and faster transfer of patients.
School Nurses Provide Daily Testing, As-Needed Administration of Insulin, Leading to Better Glycemic Control in Low-Income Students With Diabetes
A diabetes care center works in partnership with middle and high school nurses to proactively monitor glycemic levels and administer doses of long-acting insulin as needed, leading to a substantial reduction in hemoglobin A1c levels in students with poorly controlled type I diabetes.
Cultural Competence: Essential Ingredient for Successful Transitions of Care
This guide for health care professionals provides information about culture and cultural competence for delivery of health services to patients.
Medication Reconciliation Essential Data Specifications
This resource can help health care providers collect, communicate, and manage critical information needed for medication reconciliation when patients move from one practice setting or level of care to another.
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.
Improving on Transitions of Care: How to Implement and Evaluate a Plan
This guide helps health care institutions develop and implement processes for sending and receiving patients from one care setting to another. The information and plans provided allow institutions to measure their performance in transitions of care and identify areas for improvement.