Nurse Practitioner–Led Transitional Care Program Does Not Reduce Readmissions During Period Between Discharge and Followup Appointment
A nurse practitioner–led service to bridge the gap in care for recently discharged patients awaiting a followup appointment did not reduce the rate of unplanned readmissions.
System-Integrated Program Coordinates Care for People With Advanced Illness, Leading to Greater Use of Hospice Services, Lower Utilization and Costs, and High Satisfaction
The Advanced Illness Management program supports Medicare patients with advanced illness and their families in making patient-centered decisions, leading to greater use of hospice care, lower inpatient and ambulatory utilization and overall care costs, and high levels of patient, family, and physician satisfaction.
Home Health Nurses and Care Managers Use Software-Aided Medication Review Protocol for Frail, Community-Dwelling Seniors, Leading to More Appropriate Medication Use
Care staff use software-based protocols to screen older clients’ medications and collaborate with pharmacists and physicians to reduce the risk of medication errors and adverse effects, leading to more appropriate medication use and fewer cases of duplicative medications.
Health Coach Program in a Medical Group Improves Self-Care and Decreases Readmissions for High-Risk, Chronically Ill Patients
Dartmouth-Hitchcock Clinic assigns 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 has reduced readmission rates and costs among elderly patients.
Better Integration of Home Health Aides Into the Health Care Team Improves Patient Functionality
A team-building program at the largest home care agency in the country integrated home health aides into the health care team and resulted in enhanced functional status for patients, including being better able to move independently from a bed to a wheelchair or chair and better able to walk without support.
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