Care Transitions Profiled by New York Times
In “Groups Try Simple Steps to Avoid Hospital Rebound,” states participating in the Care Transitions project were profiled. The article was published in the New York Times December 8.
Heart Failure Patient Tool Now Available: Teach-Back Practice and CHF Medications Tool - PDF
New Re-engineering Discharge Patient Survey in English (or Spanish) - PDF
Care Transitions Profiled by New York Times in “Groups Try Simple Steps to Avoid Hospital Rebound”
60 Minutes, “The Cost of Dying”
End-of-Life Preferences for Care: Advance Care Planning
Hospital Discharge Summaries: Accuracy of Medication Documentation
Nursing Home Residents with Lower Respiratory Tract Infection: Improving Outcomes
Life’s End – Skin Changes Including Pressure Ulcers
Home Health Care Electronic Transition Tools Developed
On the Prospects for a Blame-Free Medical Culture
Care Transitions Conference January 21: Come Hear Nationally Acclaimed Speakers and See Where the Valley Stands in Relation to the Rest of the U.S.
Save the date! This Care Transitions conference will be the talk of the Rio Grande health care community. President and CEO of the Institute for Healthcare Improvement Dr. Donald M. Berwick calls speaker Dr. Joanne Lynn “a national treasure—the most articulate, courageous, and
scientifically-grounded voice in our nation for the improvement of health care for people approaching the end of life.”
In addition, Dr. Ileana Pina, internationally recognized for her research in rehabilitation and recovery of heart failure patients, will present “Hospital to Home (H2H),” a live webinar. Dr. Pina is a regular speaker at the World Congress of Cardiology in Argentina, Spain and Europe.
Five dynamic speakers and a panel discussion by representatives from the Valley’s own health care community have been assembled to spark your efforts as you enter the final phase of the Care Transitions collaborative project. FREE CME and CNE. Reserve your seat or find out more now!
Heart Failure Patient Tool Now Available: Teach-Back Practice and CHF Medications Tool (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 covers 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. Use this tool to promote both health literacy and patient safety.
New Re-engineering Discharge Patient Survey in English (PDF) or Spanish (PDF)
This new patient discharge survey tool can be used to collect Re-engineering Discharge (RED) monitoring data in conjunction with the Excel RED Data Monitoring Collection Tool.
Back to Top | Improving Patient Care | Health Care Reform | Other Health Care News
Care Transitions Profiled by New York Times in “Groups Try Simple Steps to Avoid Hospital Rebound”
Hospitals in the 14 states participating in the Care Transitions project have already begun to see readmissions decrease, according to this article published in the New York Times on December 8. Louisiana is using health care coaches at five hospitals in Baton Rouge to guide high-risk patients through the discharge process and check on them during the first month after their hospital release. Of 145 patients coached so far, only 7 were rehospitalized. The article includes a list of top risks for rehospitalization and quotes Dr. Barry Straube, chief medical officer of the Centers for Medicare & Medicaid Services, who says, “Even the best hospitals have room for improvement.”.
60 Minutes, “The Cost of Dying”
This program is a frank discussion of choices to be made at end-of-life and costs involved. According to 60 Minutes, “Last year Medicare paid $50 billion just for doctors and hospital bills during the last two months of patients’ lives—more than the budget of the Department of Homeland Security or the Department of Education.” One doctor interviewed during the program said that worse than a loved one dying is a loved one dying badly—that is suffering or connected to machines when a better outcome cannot be expected. The program ran on CBS November 22, 2009. Enter "The Cost of Dying" in the search box at the top right.
End-of-Life Preferences for Care: Advance Care Planning
Research funded by the Agency for Healthcare Research and Quality (AHRQ) shows that, although most patients are willing to talk about end-of-life care, the majority have not taken part in advance care planning. Research findings offer providers help for predicting what debilitated patients who are unable to decide for themselves might choose based on choices made by others in similar situations.
Hospital Discharge Summaries: Accuracy of Medication Documentation
This analysis of medication transcription errors found similar error rates in both handwritten and electronic discharge summaries. The most frequent type of error was medication omission. The authors recommend incorporating medication information into electronic discharge summaries to decrease error rates for both types of documentation.
For Hospitals: “Patient and Family Engagement in Healthcare Quality and Safety” Guide Is in Development
A team of organizations led by the American Institutes for Research and including the Joint Commission and Consumers Advancing Patient Safety (CAPS), among several others, are partnering to promote greater patient and family involvement in the care provided within hospital settings. The main goal of this project is to develop a patient and family hospital engagement guide. To learn more, go to the Consumers Advancing Patient Safety (CAPS) home page, scroll down to the bottom right, and find the article describing the project’s partners, goals, tasks and contact information for those leading the project under “Latest News” and “Developing a Guide to Patient and Family Engagement in Healthcare Quality and Safety in the Hospital Setting.”
For Patients Not Proficient in English, and the Deaf and Hard of Hearing, Video Highlights Tools Healthcare Organizations Can Use
To help health care organizations with challenges associated with serving increasingly diverse patient populations, The Joint Commission and the U.S. Department of Health and Human Services Office for Civil Rights teamed up to create a new video, “Improving Patient-Provider Communication.” The video supports health care organizations in building language access. This link streams from The Joint Commission’s “Hospitals, Language, and Culture” Web page, where a study of how 60 U.S. hospitals provide health care to culturally and linguistically diverse patient populations can also be found.
Care Coordination Practices & Measures Recommended by National Quality Forum
Download a PDF of the draft report
A National Quality Forum (NQF) Steering Committee representing a range of stakeholder perspectives reviewed the NQF-endorsed Framework for Care Coordination and National Priorities Partnership (NPP) care coordination goals and developed recommendations. In its draft report, NQF advocates 25 preferred practices and 10 performance measures for measuring and reporting care coordination. The Care Transition measures start on page 60 of the draft.
Nursing Home Residents with Lower Respiratory Tract Infection: Improving Outcomes
Lower respiratory tract infection (LRI) is the number one cause of death and hospitalization in nursing home residents. Diagnosing LRIs in older adults is often difficult as signs and symptoms are not always obvious. Researchers have developed a prediction rule that helps identify pneumonia without a chest
X-ray. Another predictive model assists health care professionals identify residents at low risk of dying from LRIs and so helps to prevent hospitalization and the complications associated with it.
Life’s End – Skin Changes Including Pressure Ulcers (PDF)
Pressure ulcers often occur in conjunction with life-threatening illnesses. Skin Changes at Life’s End (SCALE) is a term for the deterioration of the skin organ at end-of-life. This article details ten consensus statements developed by a panel of wound care and palliative medicine experts. The statements include the panel’s recommendations. In the absence of documentation and education, “it is often difficult for patients and others to understand why patients developed wounds, unless the care provided was substandard; a potential risk management issue,” says author Elizabeth Hogue. (Copyrighted article used with permission.)
Empowered Patient Coalition
The goal of this coalition is to engage the public in health care improvement efforts and personal patient support. It seeks to connect with potential members by using education, information and the distribution of a toolkit. In addition, a searchable advocate directory on the Empowered Patient Coalition Web site provides access to other patient-safety related information.
Back to Top | Annoucements and Education | Health Care Reform | Other Health Care News
How Can Medicare Lead Delivery System Reform? (PDF)
The authors of this brief advocate moving away from the fee-for-service system we now use, which rewards volume and complexity of care, to one that promotes better care and better value. Although difficulties associated with containing health care costs have dogged health care reform for 50 years, the current system is unsustainable. Providers need to be held accountable for every part of the patient’s care, including quality, outcomes and cost. Medicare, the authors say, may be a good starting place for reforming the health care delivery system.
Back to Top | Annoucements and Education | Improving Patient Care | Other Health Care News
Home Health Care Electronic Transition Tools Developed
This report explains the effect of a redesigned, electronic version of the “Home Health Certification and Plan of Care” form (Form CMS-485). The report focuses on ensuring that patient referral information is complete and that evidence-based home health care is provided. A Web-based system (“e-transitions”) that furnished electronic access to the information was developed and pilot tested. The Web-based system allowed the design and generation of alerts.
On the Prospects for a Blame-Free Medical Culture
Asking physicians to view errors in a systems context—a necessary stage in developing a blame-free culture—poses difficulties, as physicians still think of errors in terms of personal failings.
Back to Top | Annoucements and Education | Improving Patient Care | Health Care Reform
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.
http://caretransitions.tmf.org | 1-866-439-6863 | 512-334-1775 fax | caretransitions@tmf.org
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-09-123