There are health reform requirements that improve the efficiency of care, reduce duplication and integrate the continuum of care. This section contains information and resources on care coordination and delivery reform.
Avoiding Hospital Readmissions
Patient-Centered Medical Homes
AHRQ Project RED —The ReEngineered Discharge
MHA in collaboration with HRET hopes to bring this program to Missouri in late 2010 or early 2011. Project RED 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. It provides a set of 11 discrete, mutually reinforcing components provided by a Discharge Advocate and reinforced by a telephone call after discharge by a clinical pharmacist.
H2H – Hospital to Home —The Hospital to Home (H2H) national quality initiative, co-sponsored by the American College of Cardiology and the Institute for Healthcare Improvement, is an effort to improve the transition from inpatient to outpatient status for individuals hospitalized with cardiovascular disease.
The Care Transitions InterventionSM was designed in response to the need for a patient-centered, interdisciplinary intervention that addresses continuity of care across multiple settings and practitioners. The overriding goal of the intervention is to improve care transitions by providing patients with tools and support that promote knowledge and self-management of their condition as they move from hospital to home.
National Guideline Clearinghouse - Evidence-based guideline resources to assist users in the prevention of the ten CMS-identified hospital-acquired conditions.
The IHI Improvement Map™ is an online tool that distills the best knowledge available on the key process improvements that lead to exceptional patient care.