Care Across Settings
On March 29, 2012, the Robert Wood Johnson Foundation held a briefing in Washington, DC to highlight the work of Jeffrey Brenner, MD. Brenner, a local Camden, N.J., physician, spurred a national health discussion with a feature in the New Yorker describing his work improving health care in one of the poorest and most dangerous cities in the country.
At the briefing, Brenner discussed his work identifying "hot spots" in and beyond New Jersey, and colleagues from Maine and Delaware discussed their local efforts to address high-utilizers. The...
The Aligning Forces for Quality November 2011 National Meeting was held in Washington DC and was broken up into three distinct tracks: Payment, Care Across Settings, and Cost. View video highlights on discussions and lectures below!
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When a patient moves across settings, like from a hospital to a nursing home, they are particularly vulnerable. Lapses in care, miscommunication of information between providers, mixups with medication – all are possible side effects of “handoffs” that are not well coordinated.
AF4Q Alliances have done significant work to improve the quality of care in hospital settings, and are connecting these efforts to improve care across settings. Alliances are working to design care delivery systems that focus on the continuity of care, avoid unnecessary risks in quality and safety, and promote coordination between providers.
Eric Coleman, MD, MPH from the University of Colorado at Denver, is a leader in improving quality and safety during times of “hand offs.” In a conversation with AF4Q communities, Dr. Coleman provides an overview of evidence-based transitional care models that have improved patient outcomes and reduced the cost of care. He showcases the Care Transitions Intervention (CTI)—a 4 week program for patients with complex care needs transitioning from hospital to home and which emphasizes coaching and self-care management. Dr. Coleman described CTI’s impact on achieving higher value health care in an era of reform and shares specific lessons, strategies, and implementation resources for hospitals interested in adopting this model of care.