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Care transitions

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Nurse and Patient Perceptions of Discharge Readiness in Relation to Postdischarge Utilization

May 1, 2010 | Journal Article

Formalizing nurse assessment of patients' readiness for discharge could identify at-risk patients and reduce avoidable health care use.

Age-Related Differences in Perception of Quality of Discharge Teaching and Readiness for Hospital Discharge

May 1, 2010 | Journal Article

Older adults have different discharge needs than the general population and require more help in making care transitions.

Collecting Data to Identify Disparities and Measure Heart Care Quality

March 24, 2010 | Story

Duke University Hospital and the health system wanted to improve cardiac care for African-American and Latino populations by identifying and analyzing disparities and developing tools that would better serve them.

Improving Heart Care through Better Data and Communications

March 24, 2010 | Story

A multidisciplinary team redesigned Montefiore Medical Center's patient registration system to collect data on race, ethnicity and preferred language, and developed a procedure to provide faster treatment for heart attack patients.

Combining Better Systems and Intensive Patient Education for Better Heart Care

March 24, 2010 | Story

Del Sol Medical Center improved its patient chart review and discharge processes, and enhanced its heart failure center, with support from Expecting Success.

The Revolving Door of Rehospitalization from Skilled Nursing Facilities

January 1, 2010 | Journal Article

Little research documenting the frequency and costs of rehospitalization has been published and little is known about the underlying nature of these rehospitalizations or how they vary geographically. This paper looks at these issues and attempts to fill that gap.

Prisoners Returning Home in the Bronx and Brooklyn Find Reentry Services Located Far Away in Manhattan

August 27, 2009 | Program Results Report

An electronic database and map of reentry services available to prisoners returning from New York City's jails to communities in its five boroughs finds services are often inaccessible.

Connecting Hospitalized Patients One-on-One with Other Patients Who Have the Same Illness

May 11, 2009 | Program Results Report

From 1994 to 2007, staff at Friends' Health Connection (originally called Long Distance Love), New Brunswick, N.J., created and ran a program that enables hospitalized patients to communicate one-on-one with another patient who has the same illness.

Section 5: How-To Guides

February 4, 2009 | Toolkit

How-to guides supported through TCAB, a national program of RWJF and the Institute for Healthcare Improvement, offer detailed steps to implement select aspects of the program.

Creating Lifelong Communities

January 1, 2009 | Journal Article

This article explores the issue of aging and longevity, and describes one region's response to the growing population of seniors.

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