NC ACT strives to develop a repository of useful care transitions resources with the goal of connecting organizations and individuals with information, tools, and best practices.
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5 Key Areas Known to Reduce Avoidable Readmissions
RARE (Reducing Avoidable Readmissions Effectively) is a campaign that calls upon hospitals and others in the care continuum to focus on five areas known to reduce avoidable readmissions. By implementing and spreading these best practices, hospitals can become more effective, more rapidly, in reducing avoidable readmissions. Through the RARE Campaign, hospitals can choose to work on any of the five key areas known to reduce avoidable readmissions.
Care Paths provides Advance Care Planning services to individuals and their families. Our services include educating individuals on the importance of advance directives, how to document their wishes, as well as how to ensure a person’s choices are communicated with the healthcare team.
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NC ACT Webinars
NC ACT Hosts Webinars, partners with communities for regional Stakeholder Meetings, hosts annual Summits, and actively engages community organizations who work to improve Care Transitions across the continuum of care. As a result of these activities, we regularly gather new resources and best practices that we will feature on a regular basis.
Tools & Resources for Care Transitions Organizations
Formal Multidimensional Programs to Improve Care Transitions
Care transitions coaches support patients by providing specific tools and teaching self-management skills to ensure their needs are met during the transition from the acute care setting to home.
Multidisciplinary, comprehensive in-hospital planning and home follow-up. Transitional Care Nurses follow patients from the hospital into the home to provide services designed to streamline plans of care, interrupt patterns of frequent acute hospital and emergency department use and prevent health status decline.
Toolkit for improving hospital discharge, including screening/assessment tools, discharge checklist, transition record, teach-back process, risk-specific Interventions and written discharge Instructions.
HHQI website has several BPIPs. This comprehensive manual assists home health agency leadership and staff to identify tools and processes to improve patient transitions; focus on the four pillars, or conceptual domains, of patient transition; includes tools and resources for patients and staff, guidelines and podcasts.
Toolkit for SNF personnel to reduce avoidable hospital admission. Three types of tools: 1) communication; 2) clinical care paths; and 3) advance care planning. Utilization specified for selected members of the care team. Newly revised INTERACT II tools can help reduce avoidable acute care transfers.
The Institute for Healthcare Improvement (IHI) STAAR initiative aims to reduce rehospitalizations by working across organizational boundaries in four states – Massachusetts, Michigan, Ohio, and Washington – and by engaging payers, state and national stakeholders, patients and families, and caregivers at multiple care sites and clinical interfaces.
IHI How-to Guide: Post Acute
IHI How-to Guide: Clinical Office Practice
IHI How-to Guide: Home Health
Standardized discharge intervention; includes patient education, comprehensive discharge planning, post-discharge telephone reinforcement.
The Bridge model is a person-centered, social work-led, interdisciplinary model of transitional care. Bridge emphasizes collaboration among hospitals, community-based providers, and the Aging Network in order to ensure a seamless continuum of health and community care across settings.
This change package was developed by the North Carolina IMPaCT: Advancing and Spreading Primary Care Transformation project, through the Cecil G. Sheps Center for Health Services Research in close collaboration with Community Care of North Carolina, NC Area Health Education Centers, and the NC Healthcare Quality Alliance.
This material was prepared by Colorado Foundation for Medical Care (CFMC), the Integrating Care for Populations & Communities National Coordinating Center, 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.
Health literacy is a major focus of research and practice at the University of North Carolina at Chapel Hill (UNC-CH). In 2007, the Sheps Center for Health Services Research established the Program on Health Literacy to promote collaboration and dissemination across the UNC-CH campus and beyond. The Program on Health Literacy represents a collaborative effort of the UNC Schools of Medicine, Nursing, Public Health, Dentistry, Pharmacy and Education as well as community organizations and neighboring universities. The program’s primary goal is to serve as a clearinghouse for materials related to health literacy and patient education that can support research and clinical efforts in this field.
This toolkit is based on the Medications at Transitions and Clinical Handoffs (MATCH) Web site. MATCH was developed by Gary Noskin, M.D., and Kristine Gleason, R.Ph., of Northwestern Memorial Hospital in Chicago, Illinois, through the support of Agency for Healthcare Research and Quality (AHRQ) Grant No. 5 U18 HS015886 and collaboration between Northwestern University Feinberg School of Medicine and The Joint Commission.
This toolkit accompanies the Hospital Guide to Reducing Medicaid Readmissions, which offers indepth information about the unique factors driving Medicaid readmissions and a step-by- step process for designing a locally relevant portfolio of strategies to reduce Medicaid readmissions. Some of the tools are adaptations of best-practice approaches to make them more relevant to the Medicaid population; many tools were newly developed through this project. This introduction offers an overview of the tools available in the package by briefly describing what they contain, who should use them, and how much time they take to use.