Useful Online Resources
National Media Alerted to Care Transitions Project Sites (PDF)
Centers for Medicare & Medicaid Services cites need for eliminating “fragmented care” to avoid unnecessary hospitalizations among nation's Medicare beneficiaries.
Keeping Patients at Home: A Home Health Program to Address Important Causes of Rehospitalization
This Performance Improvement program helps home health agencies address the most important causes of preventable hospitalizations. Practical self-guided materials draw upon recognized professional practice standards and Medicare coverage guidelines. This project is supported by a grant through the Agency for Healthcare Research and Quality.
Heart Failure Society of America
A patient-education and awareness Web site on how to successfully manage heart failure. This helpful informational guide, Living with Heart Failure for Patients and Families (45 pages, 1.46MB PDF), advises heart failure patients and their families on treatments and lifestyle changes, such as diet and nutrition, that can greatly enhance their quality of life.
The Care Transitions Program led by Dr. Eric Coleman
The Institute for Health Care Improvement
National Transitions of Care Coalition
The National Transitions of Care Coalition (NTOCC) was formed in 2006 bringing together thought leaders, patient advocates, and health care providers from various care settings dedicated to improving the quality of care coordination and communication when patients are transferred from one level of care to another. This site offers information and resources for patients, health care professionals and policy makers.
Project RED: Re-Engineering Discharge
This project re-engineers the workflow process and improves patient safety for patients from a network of Community Health Centers discharged from a general medical service at an urban hospital serving a low-income, ethnically diverse population. The "Re-engineered Hospital Discharge" (Project RED) intervention provides a set of 11 discrete, mutually reinforcing components provided by a Discharge Advocate and re-enforced by a telephone call after discharge by a clinical pharmacist.
Self-Management: Motivate Healthy Habits
Stanford Patient Education Research Center
Heart Failure Society of America
Guidelines for treatment of acute heart failure.
American College of Cardiology and American Heart Association
Guidelines (PDF) for treatment of chronic heart failure.
American Association of Heart Failure Nurses (AAFHN)
The AAHFN is a specialty organization dedicated to advancing nursing education, clinical practice and research to improve heart failure patient outcomes.
Colorado Foundation for Medical Care - Care Transitions Theme Web Site
This Web site supports the 14 quality improvement organizations across the nation that will implement Care Transitions projects in select communities. Care Transitions focuses on patient-centered care that empowers Medicare beneficiaries to knowledgeably move through care settings.
Ask Me 3 - National Patient Safety Foundation
Ask Me 3 is an educational program provided by the Partnership for Clear Health Communication at the National Patient Safety Foundation - a coalition of national organizations that are working together to promote awareness and solutions around the issue of low health literacy and its effect on safe care and health outcomes.
How's Your Health Checkup
A two step personalized guide to the best health care and medical care. First you complete a health checkup and then use helpful methods and tools to improve your health care. HowsYourHealth.org uses a cooperative network of physicians, nurses, and researchers affiliated with Dartmouth Medical School has developed approaches to make care truly responsive to the needs of the population. They use research to make sure the questions and information really helps you take better care of yourself and helps you get better health care.
Transforming Care at the Bedside (TCAB)
TCAB is a national program designed to improve the quality and safety of patient care on medical and surgical units, to increase the vitality and retention of nurses, and to improve the effectiveness of the entire care team.
How-to Guide: Creating the Ideal Transition Home for Patients with Heart Failure
This How-to Guide builds upon relevant research and published literature, and integrates what Transforming Care at the Bedside (TCAB) hospitals have learned as they strive to dramatically improve the quality of care for patients discharged from the hospital to home or to another health care facility.
Teach-Back Resources
By using clear health communication techniques, you can help your patients to better understand their condition and follow your instructions for better health outcomes. The following links provide additional research on the Teach-Back methodology:
- Case & Commentary - Agency for HealthCare Reseach and Quality:
- Help Your Patients Succeed: Tips for Improving Communication With Your Patients - Pfizer Clear Health Communication Initiative:
- Confirming Understanding with the Teach-Back Technique - Boston.com
- Promising Practices for Patient-Centered Communication with Vulnerable Populations: Examples from Eight Hospitals - The Commonwealth Fund
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Teach-Back Practice and CHF Medications Tool (544kbs PDF)
Nurses in hospitals, nursing homes, home health agencies and physician offices will find this tool useful for teaching Congestive Heart Failure (CHF) patients about their medications. Included are a cover reminder card, nine medication cards, three core measure (AMI, CHF and Pneumonia) cards and a card listing ACE-inhibitors and beta blockers. Each medication card includes: 1) How the class of drug works, 2) What problems to report to the doctor/nurse, and 3) The brand or generic drug names by class.
Patients are asked, in a shame-free environment, to simply repeat back what you have taught them in their own words. You say, “I want to make sure I explained this clearly. When you get back home in a few days, what will you tell your [friend or family member] about [key point just discussed]?” The deck of cards is easy to print and use. By employing it, you promote both health literacy and patient safety.
ECHO Nursing Facility Recommendations (28 page, 1.07MB PDF)
The California Commission for Compassionate Care oversaw the development of these recommendations in tandem with a 22-member inter-organizational statewide task force formed to improve end-of-life care in California skilled nursing facilities. Known as the ECHO (Extreme Care, Humane Options) Long-Term Care Task Force, the group field-tested these recommendations in 1999 prior to final revisions, and then used them extensively in the year 2000 training program described in the link.
Hospital-Based Palliative Care
The California Hospital Initiative in Palliative Services (CHIPS) was a two-year project that successfully assisted 38 hospitals throughout California in developing or expanding palliative-care services.
Health Care Innovations Exchange
The Health Care Innovations Exchange is an AHRQ program designed to support health care professionals in sharing and adopting innovations that improve the delivery of care to patients. Explore this site to find innovative strategies and quality-related tools, learn how to improve your organization's ability to innovate and adopt new ideas, and interact with innovators and adopters.
The Mid-America Coalition on Health Care
The Mid-America Coalition on Health Care was is the principal organization in the Kansas-Missouri region bringing together major employers and all healthcare delivery stakeholders (physicians and medical societies, health plans, hospitals, unions, pharmaceutical companies, academic institutions, public health and bi-state governmental units) to address the rising costs of health care and improve the health and wellness of employees and all residents of the Kansas City area.
Using Population Segmentation to Provide Better Health Care for All: The “Bridges to Health” Model
The “Bridges to Health” model divides the population into eight groups, each with its own definitions of optimal health and its own priorities among services. Interpreting these population-focused priorities in the context of the Institute of Medicine’s six goals for quality yields a framework that could shape planning for resources, care arrangements and service delivery, thus ensuring that each person’s health needs can be met effectively and efficiently.
National Quality Forum Announces Priorities for Improving Health Care
The National Priorities Partnership announced in November 2008 the specific goals it will strive to meet in improving targeted areas of healthcare. The partnership—a coalition convened by the National Quality Forum—explains the goals in its report Aligning Our Efforts to Transform America’s Healthcare Goals. The partnership 28 groups that have agreed to collaborate on a core set of improvements.
In Chronic Condition: Experiences of Patients with Complex Health Care Needs, in Eight Countries, 2008
A 2008 survey of chronically ill adults in Australia, Canada, France, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States found major differences in health care access, safety, and efficiency, with U.S. patients at particularly high risk of forgoing care because of costs and experiencing errors or inefficient, poorly organized care.
Tracking the Care of Patients with Severe Chronic Illness (PDF)
From the Dartmouth Atlas of Health Care, this edition looks in detail at the causes and effects of supply-sensitive care on the treatment of the chronically ill. Chapter 3 specifically focuses on hospital care and the variances of care patients receive.
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