Huddle for Care – An online community for transitional care implementers.

^NEWFEBRUARY 2016 STORY:
Creating improved medical management in community Skilled Nursing Facilities

Scott & White Memorial Hospital & Medical Center improved medical management in SNFs to reduce hospital readmissions.

4 min. read

0

^NEWFEBRUARY 2016 STORY:
Creating improved medical management in community Skilled Nursing Facilities

Matthew Boettcher
^NEWFEBRUARY 2016 STORY:
Settle patients into their new environment with a handoff tool

To improve care transitions for individuals with cognitive impairments, Dominican Hospital developed a support care handoff tool.

4 min. read

0

^NEWFEBRUARY 2016 STORY:
Settle patients into their new environment with a handoff tool

Dona Putnam
^NEWJANUARY 2016 STORY:
Improving care for children with medical complexity

Duke Children's Complex Care Service aims to coordinate longitudinal care across the continuum for children with medical complexity.

4 min. read

0

^NEWJANUARY 2016 STORY:
Improving care for children with medical complexity

David Ming
^NEWJANUARY 2016 STORY:
Building a care transitions model with a CCTP for high risk patients

Hallmark Health System, Mystic Valley Elder Services, Somerville-Cambridge Elder Services and Cambridge Health Alliance developed a program to enhance existing discharge practices and patient care at multiple service locations.

2 min. read

0

^NEWJANUARY 2016 STORY:
Building a care transitions model with a CCTP for high risk patients

Cheryl Warren
^NEWJANUARY 2016 STORY:
Connect and check-in with patients after discharge

One integral component of reducing our readmission rate from 9 percent to 5 percent was conducting 72-hour callbacks.

2 min. read

1

^NEWJANUARY 2016 STORY:
Connect and check-in with patients after discharge

Heather Rogers
^NEWJANUARY 2016 STORY:
Easing the discharge process through a comprehensive readmissions reduction plan

We are a Critical Access Hospital that began with a 9 percent readmissions rate in 2011. Through team collaboration we have been able to decrease our readmissions rate.

3 min. read

0

^NEWJANUARY 2016 STORY:
Easing the discharge process through a comprehensive readmissions reduction plan

Yolanda Ryckman
^NEWDECEMBER 2015 STORY:
A health system approach to opioid safety

Duke has taken a broad approach to opioid safety. This has included developing guidelines and tools. The next step involves reaching out to our clinicians.

3 min. read

0

^NEWDECEMBER 2015 STORY:
A health system approach to opioid safety

Lawrence Greenblatt
^NEWDECEMBER 2015 STORY:
Educating physicians to reduce readmissions in a rural setting

We reduced our readmission rate from 9 percent to 5 percent in a very short period of time. We are happy to share our tips while continuing to learn and improve!

2 min. read

1

^NEWDECEMBER 2015 STORY:
Educating physicians to reduce readmissions in a rural setting

Heather Rogers
^NEWDECEMBER 2015 STORY:
Reducing emergency department overuse with the E.C.H.O Program (Emergency Care Helping Others)

The E.C.H.O Program helped reduce the overuse of the emergency department (ED) as a primary care provider (PCP) by uninsured and underinsured patients.

2 min. read

1

^NEWDECEMBER 2015 STORY:
Reducing emergency department overuse with the E.C.H.O Program (Emergency Care Helping Others)

Christine Nesheim
^NEWNOVEMBER 2015 STORY:
Patient centered approach to reducing readmissions

We utilized LEAN performance improvement tools to analyze readmissions and implement improvements to reduce readmissions.

2 min. read

0

^NEWNOVEMBER 2015 STORY:
Patient centered approach to reducing readmissions

Carrie Erlinger
^NEW NOVEMBER 2015 STORY: Establishing bedside delivery of high-risk medications following an adverse event

Following a patient death several days after discharge to home, HealthSouth Valley of the Sun partnered with a local pharmacy to deliver high-risk medications to patients' bedsides before discharge.

2 min. read

0

^NEW NOVEMBER 2015 STORY: Establishing bedside delivery of high-risk medications following an adverse event

Rob Kronenberg
The value of making a connection with the partner SNF

UCSF sends partner SNFs an email with patient-specific concerns and contact information when transferring patients to them

3 min. read

5

The value of making a connection with the partner SNF

Maureen Carroll
Knowing when to start goals of care conversations

UCSF recommends that care teams start goals of care conversations after three readmissions to explore alternatives to hospitalization

3 min. read

1

Knowing when to start goals of care conversations

Maureen Carroll
Using patient stories to gain understanding and initiate org change

UCSF’s care transitions team uses patient stories to help the medical team connect emotionally with their program and patients

2 min. read

0

Using patient stories to gain understanding and initiate org change

Maureen Carroll
Employing pharmacists and pharm techs to tackle med rec and education

At El Camino Hospital, pharmacists and pharmacy technicians play a key role in medication reconciliation and education

2 min. read

1

Employing pharmacists and pharm techs to tackle med rec and education

Ruth Zaltsmann
Coaching in chunks

SF General coaches patients in 15-20 minute chunks throughout their stay to avoid overwhelming patients and improve retention

4 min. read

2

Coaching in chunks

Richard Santana
Using experts to get buy-in with executives

VA Palo Alto brought transitional care experts to their hospital to convince their executives of the importance of reducing readmissions

2 min. read

1

Using experts to get buy-in with executives

David Renfro
Hiring from your community to better connect with patients

Highland Hospital looked to their local community to find a transitions team member who could relate and connect with patients during home visits

4 min. read

2

Hiring from your community to better connect with patients

Maia White
Creating a clinic can lower readmissions rates while saving time

Highland Hospital created a weekly COPD clinic to provide follow up care for discharged patients

4 min. read

5

Creating a clinic can lower readmissions rates while saving time

Maia White
Using ‘gut feelings’ to identify the right patients for enrollment

Peninsula Circle of Care at Mills Peninsula asks nurses for their gut predictions of which patients are at risk for readmission

3 min. read

2

Using ‘gut feelings’ to identify the right patients for enrollment

Yvonne Chan
Taking home visits out of the home

Peninsula Circle of Care coaches meet patients for “home visits” wherever they’re comfortable, even if that means at a cafe

2 min. read

2

Taking home visits out of the home

Yvonne Chan
An unexpected cause of early-dosing of medications

VA Palo Alto tailors medication schedules to their patient’s lives to minimize early-dosing

2 min. read

1

An unexpected cause of early-dosing of medications

David Renfro
From patient care boards to patient communication boards

St. Rose designed custom whiteboards for each room that patients, doctors, and nurses use to communicate with one another

2 min. read

2

From patient care boards to patient communication boards

Shogofa Zamon
The power of a little red notebook

St. Rose gives all project red patients notepads and pens when they enter the hospital and encourages them to record their questions

3 min. read

3

The power of a little red notebook

Shogofa Zamon

HELP!

Our patients aren't going to followup appointments

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Our patients aren't motivated to take care of themselves

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Our patients aren't receptive to home visits

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Our patients aren't receptive to our help

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Our patients don't feel empowered to take care of themselves

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HELP!

Our patients don't know what steps to take after leaving the hospital

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HELP!

Our patients don't understand how and why to take their medications

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Our patients face a lot of social challenges

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Our patients' health literacy is very low

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I need to keep my team motivated

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I'm struggling to build committment for care transitions

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It's hard to coordinate care across the whole care team

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It's hard to know how we're doing and how to get better

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It's not easy to coordinate with outpatient care

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We don't have the resources to make followup calls or home visits

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We don't know which patients to focus on

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We have limited resources

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We're having trouble communicating with our patients

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We're not sure what skills we need on our team

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NEW FEBRUARY 2016 STORY:Creating improved medical management in community Skilled Nursing Facilities

4 min. read

NEW FEBRUARY 2016 STORY:Creating improved medical management in community Skilled Nursing Facilities

Matthew Boettcher

NEW FEBRUARY 2016 STORY:Settle patients into their new environment with a handoff tool

4 min. read

NEW FEBRUARY 2016 STORY:Settle patients into their new environment with a handoff tool

Dona Putnam

NEW JANUARY 2016 STORY:Improving care for children with medical complexity

4 min. read

NEW JANUARY 2016 STORY:Improving care for children with medical complexity

David Ming

NEW JANUARY 2016 STORY: Building a care transitions model with a CCTP for high risk patients

2 min. read

NEW JANUARY 2016 STORY: Building a care transitions model with a CCTP for high risk patients

Cheryl Warren

^NEWFEBRUARY 2016 STORY:
Creating improved medical management in community Skilled Nursing Facilities

^NEWFEBRUARY 2016 STORY:
Creating improved medical management in community Skilled Nursing Facilities

^NEWFEBRUARY 2016 STORY:
Settle patients into their new environment with a handoff tool

^NEWFEBRUARY 2016 STORY:
Settle patients into their new environment with a handoff tool

^NEWJANUARY 2016 STORY:
Improving care for children with medical complexity

^NEWJANUARY 2016 STORY:
Improving care for children with medical complexity

^NEWJANUARY 2016 STORY:
Building a care transitions model with a CCTP for high risk patients

^NEWJANUARY 2016 STORY:
Building a care transitions model with a CCTP for high risk patients

^NEWJANUARY 2016 STORY:
Connect and check-in with patients after discharge

^NEWJANUARY 2016 STORY:
Connect and check-in with patients after discharge

^NEWJANUARY 2016 STORY:
Easing the discharge process through a comprehensive readmissions reduction plan

^NEWJANUARY 2016 STORY:
Easing the discharge process through a comprehensive readmissions reduction plan

^NEWDECEMBER 2015 STORY:
A health system approach to opioid safety

^NEWDECEMBER 2015 STORY:
A health system approach to opioid safety

^NEWDECEMBER 2015 STORY:
Educating physicians to reduce readmissions in a rural setting

^NEWDECEMBER 2015 STORY:
Educating physicians to reduce readmissions in a rural setting

^NEWDECEMBER 2015 STORY:
Reducing emergency department overuse with the E.C.H.O Program (Emergency Care Helping Others)

^NEWDECEMBER 2015 STORY:
Reducing emergency department overuse with the E.C.H.O Program (Emergency Care Helping Others)

^NEWNOVEMBER 2015 STORY:
Patient centered approach to reducing readmissions

^NEWNOVEMBER 2015 STORY:
Patient centered approach to reducing readmissions

^NEW NOVEMBER 2015 STORY: Establishing bedside delivery of high-risk medications following an adverse event

^NEW NOVEMBER 2015 STORY: Establishing bedside delivery of high-risk medications following an adverse event