Provisions within the recently passed health reform law provide support for new approaches to reducing the high cost of care for clinically complex patients. This article describes the characteristics of a recent transitional care pilot initiative that aims to reduce hospital readmissions among high-risk heart failure patients. The program was designed and implemented through a joint collaboration between a Certified Home Healthcare Agency and regional hospital. As a preliminary assessment of the impact of this program on patient outcomes, we compare the odds of rehospitalization among patients who received the transitional care services (n = 223) and a similar group of patients who received usual home care services (n = 224). Analyses indicated that patients who received the transitional care services were significantly less likely to be readmitted to the hospital than the patients in the control group. Although preliminary, our findings suggest that providing transitional care services to high-risk heart failure patients can be an effective deterrent against patterns of rehospitalization. The opportunities and challenges associated with implementing this pilot program are discussed.
This article presents a new model, Evidence-Based Practice Improvement, for improving patient care. The model merges 2 extant paradigms currently used for quality improvement initiatives-evidence-based practice and practice or performance improvement. The literature expounds on the virtues of each of these approaches, yet no authors have moved beyond parallel play between them. The merged model, Evidence-Based Practice Improvement, may provide a more effective and practical approach to reach our quality goals.
Appropriate and efficient provision of services at home requires more than skilled personnel; effective communication between the primary care provider and the agency is an often overlooked but essential tool for maintaining the patient's health in the community. A method was developed to create home care orders (the "e-485") that guides the physician through the order writing process, uploads data from the electronic medical record, and creates a legible, complete order set that can be faxed quickly to the agency. This paper describes this tool and the challenges and rewards of its implementation in an academic medical center.
This article describes the process of the spread of improvement strategies to improve relationships between professional and paraprofessional service providers within a large home healthcare organization and its partnering home health aide vendors. We describe the method for spreading the strategies, which emerged from a learning collaborative, and the successes and challenges of the spread. Two case studies highlight how the attributes of innovations and the methods for spreading them can influence the effectiveness of an improvement effort.
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