Technical Assistance for Communities
Qsource is currently identifying target communities within Tennessee and will implement improvement plans that coordinate hospital and community-based systems of care. We plan to implement three types of interventions:
- Hospital and community interventions to improve processes of care at a system level—interventions may include redesigning discharge protocols, adopting information technology solutions, or creating a new protocol for transferring hospital patients to skilled nursing facilities;
- Interventions that impact hospital readmission for specific diseases or conditions, such as acute myocardial infarction, congestive heart failure (CHF) and pneumonia—these may include, for example, CHF disease management programs or the Care Transitions Intervention (providing patients with a “transition coach” and education in self-management skills); and
- Interventions that address community-specific reasons for hospital readmission—interventions may include creating services, such as palliative care, that can decrease the readmission rate simply because patients previously had no alternative to hospitalization.
Care Transtions Toolkit
This extensive toolkit was develped to promote seamless transitions from the hospital to home, skilled nursing care, or home health care.
Care Transitions Toolkit
Other Care Transitions Links:
- Understanding Care Transitions as a Patient Safety Issue from Patient Safety & Quality Healthcare, May/June 2011. By Sara Butterfield RN, BSN, CPHQ, CCM; Christine Stegel, RN, MS, CPHQ; Shelly Glock, LNHA, MBA; and Dennis Tartaglia, MA.
- All Aboard: Hospitalists should jump on transitions-of-care train now to help solve rehospitalization problems.
- Ramping Up For Higher Acuity; Nursing Facilities Respond to the Need for Reducing Hospitalizations.
- Medicare spreads savings from Denver program: A Denver pilot project helps older patients stay out of hospitals and is expanded nationally
http://www.denverpost.com/news/ci_16843482 - “Grand Junction, Colorado: How A Community Drew On Its Values To Shape A Superior Health System” by Marsha Thorson, Jane Brock, Jason Mitchell, and Joanne Lynn. Health Affairs. 2010 29: 1678-1686.
- Aftercare Tips for Patients Checking Out of the Hospital: http://www.nytimes.com/2010/06/19/health/19patient.html?pagewanted=print
- Taking Care of Myself: A Guide for When I Leave the Hospital is a guide for patients to help them care for themselves when they leave the hospital. The easy-to-read guide can be used by both hospital staff and patients during the discharge process and provides a way for patients to track their medication schedules, upcoming medical appointments, and important phone numbers.
http://www.ahrq.gov/qual/goinghomeguide.htm - As part of The Care Transitions Project of Whatcom County (the Stepping Stones Project), Qualis Health recruited and trained some Western Washington University students to be transitions coaches for Medicare patients being discharged from St. Joseph Hospital in Bellingham, Washington. The experience was of value not only to the Medicare recipients but proved to be a worthwhile educational experience for the students. A recent article in Western Today, a Western Washington University publication, highlights some of the students’ experiences.
http://onlinefast.org/wwutoday/spotlight/wwu-students-volunteer-coaches-stepping-stones-program - How to Avoid the Round-Trip Visit to the Hospital: Carolyn M. Clancy, M.D., Director of the Agency for Healthcare Research and Quality (AHRQ), offers brief, easy-to-understand advice columns for consumers to help navigate the health care system. In her latest column, Dr. Clancy highlights the steps patients and their family members/caregivers can take to prevent an unnecessary return trip to the hospital. To read Dr. Clancy’s latest column, go to http://www.ahrq.gov/consumer/cc/cc060110.htm.
- Project Videos Provided by Qualis Health: “Going Home from the Hospital” and “Bridging Healthcare Gaps”
- “Health Tips for Older Adults”
VIDEOS: Hospital to Home
Medicare has two new videos to help caregivers and loved ones move from hospital to home smoothly:
- Planning for Your Discharge outlines the questions you should ask and preparations you should make before your
loved one leaves the hospital. - Hospital to Home provides tips for making a Hospital to Home Transition, and gives guidance on what to plan for once you’re back at home. It offers advice on talking with health care providers, preparing the home for new equipment needs, planning for additional expenses, and more.
Watch both videos online at www.medicare.gov/caregivers/
This page is funded by our Medicare QIO Program Contract.
