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Literature Review | | Derivation and validation of an index to predict early death or unplanned readmission after discharge from hospital to the community
Readmissions to hospital are common, costly and often preventable. An easy-to-use index to quantify the risk of readmission or death after discharge from hospital would help clinicians identify patients who might benefit from more intensive post-discharge care. We sought to derive and validate an index to predict the risk of death or unplanned readmission within 30 days after discharge from hospital to the community
AHRQ:Coordination Care in the Medical Neighborhood:Critical Components and Available Mechanisms
Additional Reference Articles
Transitions of Care in the Long-Term Care Continuum:(large file please be patient)
Craig C, Eby D, Whittington J. Care Coordination Model: Better Care at Lower Cost for People with Multiple Health and Social Needs. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2011
Berkowitz, R. et al. (2011). Improving Disposition Outcomes for Patients in a Geriatric Skilled Nursing Facility. Journal of the American Geriatrics Society. 59:1130-1136.
Boutwell, A. et al. (2011). An Early Look at a Four-State Initiative to Reduce Avoidable Hospital Readmissions. Health Affairs. 30, No.7:1272-1280.
Coleman, E. et al. (2005) Post Hospital Medication Discrepancies: Prevalence and Contributing Factors. Archives of Internal Medicine. Vol 165, Sep 12.
Cunningham, P., Sommers, A., (2011). Physician Visits After Hospital Discharge: Implications for Reducing Readmissions. National Institute for Healthcare Reform., Number 6, Dec. 2011.
Epstein, Arnold, M., MD., Jha, Ashick,K., MD.,MPH., Orav, E., John, PH.D. The Relationship between Hospital Admission Rates and Rehospitalizations. New England Journal of Medicine2011; 365: 2287-95.
Gawandi, Atul. January 24, 2011. The Hot Spotters. The New Yorker.
Gottlieb, Sylvester and Eby. Transforming Your Practice: What Matters Most. Family Practice Management. www.aafp.org/fpm. January 2008
Ha, A. et al. (2009). Public Reporting of Discharge Planning and Rates of Readmissions. New England Journal of Medicine. 361;27. December 31.
Health Care Leader Action Guide to Reduce Avoidable Readmissions. Commonwealth Fund, The John Hartford Foundation and the Health Research & Educational Trust. January 2010.
Jencks S, Williams M, Coleman E., (2009). Rehospitalizations Among Patients in the Medicare Fee-for-Service Program. New England Journal of Medicine. 360:1418-28.
Improving Transitions of Care. September 2010. National Transitions of Care Coalition. (NTOCC)
Lourde, Kathleen. (2011). Ramping up for Higher Acuity. Nursing Facilities Respond to the Need for Reducing Hospitalizations. Provider. January.
Mor, V, et al. (2010). The Revolving Door of Rehospitalizations from Skilled Nursing Facilities. Health Affairs. 222999, No.1 :57-64.
McCarthy, D., Klein, S. The Triple Aim: Journey: Improving Population Health and Patients’ Experience of Care, While Reducing Costs. Commonwealth Fund pub. 1421. Vol. 48.
Naylor, M., Sochalski. (2010) Scaling Up: Bringing the Transitional Care Model into Mainstream. Issue Brief. Commonwealth Fund pub. 1453. Vol. 103.
Ouslander, J. et al. (2011) Interventions to reduce Hospitalizations from Nursing Homes: Evaluation of the INTERACT II Collaborative Quality Improvement Project. Journal of the American Geriatrics Society. 59:745-753.
Patient-Centered Primary Care Collaborative (PCPCC). Core Value, Community Connections: Care Coordination in the Medical Home.
Predicting non-elective hospital readmissions: A multi-site study. Journal of Clinical Epidemiology. 53(11):1113-1118.
Rutherford P,Nielsen GA, Taylor, J, Bradke P, Coleman, E. How-to–Guide: Improving Transitions from the Hospital to Post-Acute Care Settings to Reduce Avoidable Rehospitalizations. Cambridge, MA: Institute for Healthcare Improvement. June 2011.
Sanghavi, Darshak. The Phantom Menace of Sleep Deprived Doctors. August 5, 2011. The New York Times.
Sommers, Anna, Cunningham, Peter J. (2011). Physician Visits After Hospital Discharge: Implications for Reducing Readmissions. National Institute for Health Care Reform. Research Brief Number 6. December 2011.
Steele, G. et al. (2010) How Geisinger’s Advanced Medical Home Model Argues the Case for Rapid-Cycle Innovation. Health Affairs. 29:11.
Sharma, G. et al. (2009) Continuity of outpatient and Inpatient Care by Primary Care Physicians for Hospitalized Older Adults. Journal of the American Medical Association. Vol 301, No. 16:1671-1680.
Silow-Carroll, Edwards, J. Intermountain Healthcare’s McKay-Dee Hospital Center: Driving Down Readmissions by Caring for Patients the “Right Way”. Commonwealth Fund pub. 1769. Volume 1.
Soeken K, Prescott P. (1991). Patient Intensity for nursing index: The measurement model. Research in Nursing and Health. 14(4):297-304.
The Post-Hospital Follow-up Visit: A Physician Checklist to Reduce Readmissions. California HealthCare Foundation. Issue Brief. October 2010.
Council on Aging
Akron/Canton Area Agency on Aging
Regional Community-Based Care Transitions Program
Atlanta Community Based Care Transitions Program
Healing@Home Area Agency on Aging, Region One
Merrimack Valley Care Transitions:
A Collaborative Approach Regional Community-Based Care Transitions Program
Southwest Ohio Community Care Transitions Collaborative
Web References
Project BOOST
A National initiative led by the Society of Hospital Medicine to improve the care of patients as they transition from hospital to home. BOOST provides a wealth of materials and tools to help you optimize the discharge process at your institution.
The Commonwealth Fund
A Private Foundation Working Toward a High Performance Health System.
The Hospital to Home (H2H) National Quality Improvement Initiative
The Hospital to Home (H2H) initiative, led by the American College of Cardiology and the Institute for Healthcare Improvement (IHI), is a national quality improvement campaign to reduce cardiovascular-related hospital readmissions and improve the transition from inpatient to outpatient status for individuals hospitalized with cardiovascular disease.
Institute for Healthcare Improvement
An independent not-for profit-organization based in Cambridge, Massachusetts, IHI focuses on motivating and building the will for change; identifying and testing new models of care in partnership with both patients and health care professionals; and ensuring the broadest possible adoption of best practices and effective innovations.
Interventions to Reduce Acute Care Transfers
INTERACT is a quality improvement program that focuses on the management fo acute change in resident condition. It includes clinical and educational tools and strategies for use in every day practice in long-term care facilities
The Chronic Care Model
The Chronic Care Model (CCM) identifies the essential elements of a health care system that encourage high-quality chronic disease care. These elements are the community, the health system, self-management support, delivery system design, decision support and clinical information systems. Evidence-based change concepts under each element, in combination, foster productive interactions between informed patients who take an active part in their care and providers with resources and expertise. The Model can be applied to a variety of chronic illnesses, health care settings and target populations. The bottom line is healthier patients, more satisfied providers, and cost savings.
National Transitions of Care Coalition
NTOCC believes that patients are at the center of care and can play an active role in improving communications and use tools to ensure effective transitions. We have brought together industry leaders who have created resources to help you better understand transitional challenges and empower you as part of the care giving team.
The Remington Report
The Alliance mission is to provide the latest information on health care reform, emerging models and to position home care as a integrated solution
The Transitional Care Model
The Transitional Care Model (TCM) provides comprehensive in-hospital planning and home follow-up for chronically ill high-risk older adults hospitalized for common medical and surgical conditions
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