Discharge Planning
RSSArticles
-
Patients with Parkinson’s Disease Often Lost to Follow-Up Care
Telehealth visits can improve continuity of care, quality of life, and overall health for patients with Parkinson’s disease, recent research shows. Although Parkinson’s affects 1.2 million people in the United States, there is little research on people in later stages of the disease.
-
Detailed Resource Tools for Care Coordinators and Case Managers
Case managers and care coordinators need such a wide range of knowledge about community resources to address their patients’ social determinants of health that resource tools can be a huge time-saver. For a care coordination program involving complex pediatric patients, leaders developed a series of nearly two dozen resource guides they call playbooks.
-
Inside the Indiana Complex Care Coordination Collaborative
Indiana’s Medicaid program administrators found value in embedding nurse care coordinators in primary care practices to address social determinants of health and transitional care issues in a population of children with complex medical issues.
-
Indiana Medicaid Officials Embrace Care Coordination Project
A project to improve care coordination for children with complex medical needs revealed well-trained nurse care coordinators could manage a 100-patient caseload and improve outcomes. Nurse care coordinators were embedded in primary care provider offices and were trained to provide care coordination, including helping patients with medical and social needs.
-
Clinicians Are Ethically Obligated to Consider Financial Side of Care
Clinicians should include the cost of care in discussions, help patients access charity care or financial counseling, and screen patients for social determinants of health.
-
Effectively Intervening with Patients Facing Housing Instability
The notion that housing is healthcare stems from a growing body of research that links housing instability with higher rates of morbidity and mortality. There is a moral and humanitarian case for healthcare organizations to engage on the housing issue, but there also is a business case. But precisely how healthcare organizations should go about this work is not yet well established. Thus, IHI has partnered with Community Solutions, a nonprofit organization that is working to end homelessness, to examine how healthcare can play an effective role in addressing the problem.
-
Better Care Communication Needed for Home Health
Researchers wanted to know if there is an association between home health and gaps in care coordination among providers. They found patients receiving home healthcare are sicker, experienced more functional dependencies, and reported more preventable drug-drug interactions. While home health was not associated with a difference in gaps of care coordination, it was associated with twice the risk of a preventable adverse outcome.
-
Integrated Care Teams Should Include Social Workers
Integrated care teams sometimes lack a social worker, which can undermine the team’s work and success. It is a shortsighted tactic because social workers can help with case management and care coordination in a variety of ways, including intake assessment and behavioral interventions, according to recent research.
-
Study Reveals Positive Benefits of COPD Transition Bundle
A study of a care transition bundle that included a care coordinator revealed COPD patients in the bundle cohort were less likely to be readmitted to the hospital within seven days and 30 days, but 90-day readmissions were unchanged.
-
Many Safety Net, Rural Hospitals Do Not Properly Address Social Needs
Safety net hospitals, critical care hospitals, and rural hospitals often do less than needed to address the social determinants of health of their vulnerable populations, particularly during the COVID-19 pandemic, new research shows.