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AF4Q South Central Pennsylvania hosted “Improving the Quality & Value of Health Care,” a summit for employers and providers that showcased innovations in health care delivery. Keynoting the event was Paul Grundy, who spoke about the merits of patient-centered medical homes (PCMH), which are designed to foster close relationships between consumers and their primary care physicians. PCMHs are coming alive in South Central Pennsylvania through the Planned Care Collaborative. Karen Jones, MD, explained the value to patients, providers, and employers. “By tying in the...
The 2012 Heart Failure calendar and companion nurse teaching guide are now available to help heart failure patients to take control of their condition. You Can Live with Heart Failure – Healthy Habits for...
In an article in Health Affairs (April 2011), Mary D. Naylor systematically reviews twenty-one randomized experiments that tested interventions that help the chronically ill during transitions in care and identified nine that successfully demonstrated a decrease in hospital readmissions. Many of the successful interventions shared similar features, such as assigning a nurse as the clinical manager or leader of care and including in-person home visits to discharged patients.
Under the Affordable Care Act of 2010, a variety of transitional care programs and services have been...
Two studies recently concluded that older patients who participate in transitional care programs after initial discharge from hospital are significantly less likely to be readmitted. One study indicated that patients who participate in a transitional care program were in fact 48% less likely to require hospital readmission than counterparts who chose against participation in such programs. These studies underscore the importance of a holistic approach to medical intervention, and the necessity to bridge gaps between care settings in order to achieve robust, cost-effective,...
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Electronic health records (EHRs) are considered an essential ingredient of care coordination by Medical Homes; however, detailed descriptions of how it actually happens in real life are rarely found. eHealth Initiative, working with sanofi-aventis and Health & Technology Vector (H&TV), recently concluded an exploratory project to understand how eHRs can be used to improve care coordination for complex patients. The project provided a multi-dimensional picture of this one element of transforming primary care to the medical home. It began with an operational definition of, and...
Together with St. Joseph Health System-Humboldt County and Humboldt State University's nursing department, the Community Health Alliance developed the Care Transitions Program to reduce hospital readmissions. Discharged patients who are not receiving home health or hospice care are assigned a coach who is a student nurse. Coaches meet patients in the hospital, visit them at home and then check in regularly in person or by phone at intervals up to six months after discharge. The coaches work with patients to review their medicines and check that they correspond with what the doctor...
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