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Care transitions

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Recovery of Activities of Daily Living in Older Adults After Hospitalization for Acute Medical Illness

December 1, 2008 | Journal Article

After hospitalization for illness, older adults discharged with diminished ability to take care of themselves are at high risk for death or continued disability in the following year, and are not likely to recover functions they do not regain in the first month post-discharge.

Smoothing the Transition From Hospital to Community for Older Adults in Jacksonville, Fla.

December 7, 2011 | Story

Mark LeMaire led a community partnership in Jacksonville, Fla., that placed elder care advocates in area hospitals to help discharged patients transition back to the community. The hospitals have since incorporated the program into their operations.

Adherence to Discharge Guidelines for Late-Preterm Newborns

July 1, 2011 | Journal Article

Babies born between 34 to 36 weeks' gestation are being discharged early at stubbornly high rates in some regions and types of hospitals, despite mid-1990s care guidelines and insurance mandates to cover longer hospital stays.

When Students Have an Emergency, the Brookline Resilient Youth Team Steps in

April 18, 2011 | Program Results Report

In 2004, the Brookline Community Mental Health Center and Brookline High School established the Brookline Resilient Youth Team. It provides counseling and academic help to high school students who are re-entering school after a personal emergency.

Speaking Together: National Language Services Network

April 18, 2011 | Program Results Report

Ten hospitals throughout the country joined a collaborative learning network, developed strategies to improve the quality and accessibility of their language services, and tested them using five standardized performance improvement measures.

Telephone Interpretation Services Can Serve Hospitals Well

April 6, 2011 | Program Results Report

As the project manager at the University of Michigan said: "We could just grab the phone when patients came in who spoke languages for which we don't have an interpreter."

Policy Options to Improve Discharge Planning and Reduce Rehospitalization

January 19, 2011 | Commentary

Short hospital stays, rehospitalizations and transitions among health care settings have become increasingly common. Financial policy changes should be implemented to incentivize longer hospital stays and better-coordinated post-discharge care.

Frontline Caregiver Daily Practices

January 1, 2011 | Journal Article

Compared with traditional skilled nursing homes, the Green House model allows for more time to be spent caring for and engaging residents.

Wisdom at Work: Retaining Experienced Nurses

July 1, 2010 | Program Results Report

RWJF launched Wisdom at Work: Retaining Experienced Nurses in 2006 to build an evidence base for what works to retain experienced nurses in hospital settings and to develop a better understanding of the impact of existing interventions on the work environment for older nurses.

New Services for Released Prisoners with Mental Illness in Mercer County, N.J.

June 28, 2010 | Program Results Report

Greater Trenton Behavioral HealthCare and its partners provided re-entry assistance to 176 incarcerated individuals diagnosed with mental illness through discharge planning, case management and needed follow-up services for 12 months or more.

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