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Care Transitions is a Centers for Medicare & Medicaid Services quality improvement project for Texas' Lower Rio Grande Valley administered through TMF Health Quality Institute. It is a regional, collaborative effort to reduce avoidable hospitalizations by improving patient care transitions. |
| Volume 1, Issue 7 |
May 2009 |
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| TMF Upcoming Webinar |
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The Home-Based Chronic Care Model Web Conference
Wednesday, May 13, noon (CT) 
Sign in: Password CT51
Phone: 1-800-394-5972 with access code 5627
Speaker:
Paula Suter, RN, MA, is the director, Center of Excellence for Chronic Care Management, for Baptist Home Health Network in Little Rock, Arkansas. The home-based chronic care management model was lauded by Modern Healthcare with a "Spirit of Excellence" award for quality. The Baptist Home Health Network has successfully combined emerging technology with personalized care to empower patients to better manage chronic illnesses.
Complete descriptions and registration information for TMF events >> |
| Newly Posted |
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 Visit the"What's New" section of the Care Transitions Web site to access newly posted resources and tools. |
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Care Transitions News is brought to you by
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In the News |
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One in Five Rehospitalized in 30 DaysA study published in the New England Journal of Medicine found that unplanned rehospitalizations among Medicare beneficiaries are prevalent and costly. Nearly 11.8 million, or one-fifth, of discharged patients was rehospitalized within 30 days--and half of these patients didn't see a physician after discharge. These hospitalizations cost Medicare approximately $17 billion in 2004.
National Campaign Asks Patients to Get Involved in Their Health CareThe Agency for Healthcare Research and Quality has sponsored a nationwide series of public service announcements that encourage patients to be active participants in their health care. Featuring actress and health care advocate Fran Drescher, the spots prompt patients to speak up and ask questions during health care encounters.
In 2004, the United States Pharmacopeia described 2022 cases of voluntarily reported medication reconciliation errors. Of these, 22% occurred during admission, 12% during discharge and 66% during transfer. The following year, The Joint Commission announced medication reconciliation would be a National Patient Safety Goal. Learn more about strategies to ensure the capture of an accurate medication history. (Free Medscape registration required.)
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| HOME HEALTH |
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Community-Based Medication Management for Home-Bound ElderlyThe Partners in Care Foundation Medication Management Improvement System is an evidence-based intervention specifically designed to enable social worker and nurse care managers to identify and resolve certain medication problems among frail elders living in the community.
NQF Sets Quality Standards for Home Health Care The National Quality Forum (NQF), funded through the Centers for Medicare & Medicaid Services, is seeking to establish a set of quality standards to encompass the home health patient's experience with care.
The Centers for Medicare & Medicaid Services (CMS) plans to launch a version of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey for home health agencies, according to a post in the Federal Register (April 10, pp 16401-16402). Currently a voluntary program, survey results will be posted at the CMS Home Health Compare Web site for agencies with four consecutive quarters of data. CAHPS measures the experiences of people receiving home health care from Medicare-certified home health care agencies.
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| NURSING HOMES
Medicare to Test Pay Incentives to Improve Nursing Home Care
A new four-state demonstration project from Medicare is testing if cash incentives will improve the quality of care and operations efficiency of nursing homes. Facilities in Arizona, Mississippi, New York and Wisconsin will be asked to participate.
Five-Star Data UpdatedThe Centers for Medicare & Medicaid Services updated the Nursing Home Compare Web site with five-star data on April 23. |
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PHYSICIANS and CLINICS
Make Your EMR Do More for You
Users of an electronic medical record (EMR) system are encouraged to enroll in the Institute for Healthcare Improvement's five-session series on health information technology in the physician office setting. Topics include care process redesign, clinical quality and patient safety, and efficiency issues.
Physician Continuity of Care Has Decreased
Researchers studying Medicare enrollment and claims data from 1996-2006 for patients older than 66 years found that the increasing involvement of hospitalists was associated with approximately one-third of the decrease in continuity of care during this period. | |
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This material was prepared by TMF Health Quality Institute, the Medicare Quality Improvement Organization for Texas, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 9SOW-TX-CT-09-40
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