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February 16, 2009

In today's fragmented health care system, there is a lack of coordination and continuity of care when patients transition from hospital to home or to another health care institution. The featured innovations describe programs designed to improve patient care upon hospital discharge and patient safety during intra-hospital transfers.
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Innovation Profiles:
- County Health Department Enacts Systems-Based Changes in Primary Care Sites, Leading to Enhanced Access to Care and Improved Outcomes for HIV/AIDS Patients
- Discharge Education Program Increases Patient Understanding of Treatment and Follow Up Care
- Posting Expected Discharge Date Facilitates Communication, Leads to On-Time Patient Departures and High Levels of Satisfaction
- Simple Scoring System and Action Algorithm Identifies Children at Risk of Deterioration, Leading to Fewer Codes and More Timely Transfer to Intensive Care Unit
- Transition "Tickets" Reduce Adverse Events During Patient Transports
- Transition Home Program Reduces Readmissions for Heart Failure Patients
- Urban Clinic Provides Free, Bilingual Primary and Specialty Care to Uninsured, Undocumented Immigrants

QualityTools:
- Admission Orders for Medications Prior to Admission
- BOOSTing (Better Outcomes for Older adults through Safe Transitions) Care Transitions Resource Room
- Discharge Knowledge Assessment Tool (DKAT)
- Discharge Medication Prescription Form
- Pediatric Early Warning (PEW) Score System
- Plan-Do-Study-Act (PDSA) Cycle
- The Transforming Care at the Bedside Toolkit

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Last updated: February 16, 2009.
 
 
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