Effective Care Transitions: Reducing Readmissions to Improve Patient Care and Outcomes.

Autor:	Kinard T; Tara Kinard, MSN, MBA, RN, ACM-RN, CCM, CENP, is Associate Chief Nursing Officer at Duke Health's Population Health Management Office. She is the DNP student noted during implementation of this quality improvement project, and her interests include improving health equity, patient outcomes, and care delivery for patients during care transitions.; Jill Brennan-Cook, DNP, RN, GERO-BC, is Associate Clinical Professor of Nursing at Duke University School of Nursing. Her current scholarship focuses on older adults, myeloproliferative neoplasm (MPN), and health inequities.; Sara Johnson, MBA, PMP, is the Associate Vice President, Population Health and Innovation at Duke Primary Care. In this role, Sara leads the strategic planning and project management of Duke Primary Care's Population Health programs and initiatives.; Andrea Long, PharmD, is a licensed Pharmacist and Information Technology Director, Population Health Analytics at Duke Health Technology Solutions and the Duke Population Health Management Office.; John Yeatts, MD, MPH, is a practicing internist and serves as Assistant Vice President and Chief Medical Officer of Population Health at Duke Health, as well as the Executive Director of the Population Health Management Office and Duke Connected Care, Duke's Accountable Care Organization.; David Halpern, MD, MPH, FACP, is a practicing internist and serves as the Senior Medical Director for Quality and Population Health at Duke Primary Care., Brennan-Cook J; Tara Kinard, MSN, MBA, RN, ACM-RN, CCM, CENP, is Associate Chief Nursing Officer at Duke Health's Population Health Management Office. She is the DNP student noted during implementation of this quality improvement project, and her interests include improving health equity, patient outcomes, and care delivery for patients during care transitions.; Jill Brennan-Cook, DNP, RN, GERO-BC, is Associate Clinical Professor of Nursing at Duke University School of Nursing. Her current scholarship focuses on older adults, myeloproliferative neoplasm (MPN), and health inequities.; Sara Johnson, MBA, PMP, is the Associate Vice President, Population Health and Innovation at Duke Primary Care. In this role, Sara leads the strategic planning and project management of Duke Primary Care's Population Health programs and initiatives.; Andrea Long, PharmD, is a licensed Pharmacist and Information Technology Director, Population Health Analytics at Duke Health Technology Solutions and the Duke Population Health Management Office.; John Yeatts, MD, MPH, is a practicing internist and serves as Assistant Vice President and Chief Medical Officer of Population Health at Duke Health, as well as the Executive Director of the Population Health Management Office and Duke Connected Care, Duke's Accountable Care Organization.; David Halpern, MD, MPH, FACP, is a practicing internist and serves as the Senior Medical Director for Quality and Population Health at Duke Primary Care., Johnson S; Tara Kinard, MSN, MBA, RN, ACM-RN, CCM, CENP, is Associate Chief Nursing Officer at Duke Health's Population Health Management Office. She is the DNP student noted during implementation of this quality improvement project, and her interests include improving health equity, patient outcomes, and care delivery for patients during care transitions.; Jill Brennan-Cook, DNP, RN, GERO-BC, is Associate Clinical Professor of Nursing at Duke University School of Nursing. Her current scholarship focuses on older adults, myeloproliferative neoplasm (MPN), and health inequities.; Sara Johnson, MBA, PMP, is the Associate Vice President, Population Health and Innovation at Duke Primary Care. In this role, Sara leads the strategic planning and project management of Duke Primary Care's Population Health programs and initiatives.; Andrea Long, PharmD, is a licensed Pharmacist and Information Technology Director, Population Health Analytics at Duke Health Technology Solutions and the Duke Population Health Management Office.; John Yeatts, MD, MPH, is a practicing internist and serves as Assistant Vice President and Chief Medical Officer of Population Health at Duke Health, as well as the Executive Director of the Population Health Management Office and Duke Connected Care, Duke's Accountable Care Organization.; David Halpern, MD, MPH, FACP, is a practicing internist and serves as the Senior Medical Director for Quality and Population Health at Duke Primary Care., Long A; Tara Kinard, MSN, MBA, RN, ACM-RN, CCM, CENP, is Associate Chief Nursing Officer at Duke Health's Population Health Management Office. She is the DNP student noted during implementation of this quality improvement project, and her interests include improving health equity, patient outcomes, and care delivery for patients during care transitions.; Jill Brennan-Cook, DNP, RN, GERO-BC, is Associate Clinical Professor of Nursing at Duke University School of Nursing. Her current scholarship focuses on older adults, myeloproliferative neoplasm (MPN), and health inequities.; Sara Johnson, MBA, PMP, is the Associate Vice President, Population Health and Innovation at Duke Primary Care. In this role, Sara leads the strategic planning and project management of Duke Primary Care's Population Health programs and initiatives.; Andrea Long, PharmD, is a licensed Pharmacist and Information Technology Director, Population Health Analytics at Duke Health Technology Solutions and the Duke Population Health Management Office.; John Yeatts, MD, MPH, is a practicing internist and serves as Assistant Vice President and Chief Medical Officer of Population Health at Duke Health, as well as the Executive Director of the Population Health Management Office and Duke Connected Care, Duke's Accountable Care Organization.; David Halpern, MD, MPH, FACP, is a practicing internist and serves as the Senior Medical Director for Quality and Population Health at Duke Primary Care., Yeatts J; Tara Kinard, MSN, MBA, RN, ACM-RN, CCM, CENP, is Associate Chief Nursing Officer at Duke Health's Population Health Management Office. She is the DNP student noted during implementation of this quality improvement project, and her interests include improving health equity, patient outcomes, and care delivery for patients during care transitions.; Jill Brennan-Cook, DNP, RN, GERO-BC, is Associate Clinical Professor of Nursing at Duke University School of Nursing. Her current scholarship focuses on older adults, myeloproliferative neoplasm (MPN), and health inequities.; Sara Johnson, MBA, PMP, is the Associate Vice President, Population Health and Innovation at Duke Primary Care. In this role, Sara leads the strategic planning and project management of Duke Primary Care's Population Health programs and initiatives.; Andrea Long, PharmD, is a licensed Pharmacist and Information Technology Director, Population Health Analytics at Duke Health Technology Solutions and the Duke Population Health Management Office.; John Yeatts, MD, MPH, is a practicing internist and serves as Assistant Vice President and Chief Medical Officer of Population Health at Duke Health, as well as the Executive Director of the Population Health Management Office and Duke Connected Care, Duke's Accountable Care Organization.; David Halpern, MD, MPH, FACP, is a practicing internist and serves as the Senior Medical Director for Quality and Population Health at Duke Primary Care., Halpern D; Tara Kinard, MSN, MBA, RN, ACM-RN, CCM, CENP, is Associate Chief Nursing Officer at Duke Health's Population Health Management Office. She is the DNP student noted during implementation of this quality improvement project, and her interests include improving health equity, patient outcomes, and care delivery for patients during care transitions.; Jill Brennan-Cook, DNP, RN, GERO-BC, is Associate Clinical Professor of Nursing at Duke University School of Nursing. Her current scholarship focuses on older adults, myeloproliferative neoplasm (MPN), and health inequities.; Sara Johnson, MBA, PMP, is the Associate Vice President, Population Health and Innovation at Duke Primary Care. In this role, Sara leads the strategic planning and project management of Duke Primary Care's Population Health programs and initiatives.; Andrea Long, PharmD, is a licensed Pharmacist and Information Technology Director, Population Health Analytics at Duke Health Technology Solutions and the Duke Population Health Management Office.; John Yeatts, MD, MPH, is a practicing internist and serves as Assistant Vice President and Chief Medical Officer of Population Health at Duke Health, as well as the Executive Director of the Population Health Management Office and Duke Connected Care, Duke's Accountable Care Organization.; David Halpern, MD, MPH, FACP, is a practicing internist and serves as the Senior Medical Director for Quality and Population Health at Duke Primary Care.
Jazyk:	angličtina
Zdroj:	Professional case management [Prof Case Manag] 2024 Mar-Apr 01; Vol. 29 (2), pp. 54-62. Date of Electronic Publication: 2023 Nov 23.
DOI:	10.1097/NCM.0000000000000687
Abstrakt:	Purpose/objectives: Care transitions from one setting to another are vulnerable spaces where patients are susceptible to complications. Health systems, accountable care organizations, and payers recognize that care transition interventions are necessary to reduce unnecessary cost and utilization and improve patient outcomes following a hospitalization. Multiple care transition models exist, with varying degrees of intensity and success. This article describes a quality improvement project for a care transition model that incorporates key elements from the American Case Management Association's Transitions of Care Standards and the Transitional Care Management services as outlined by the Centers for Medicare & Medicaid Services. Primary Practice Setting: A collaboratively developed care transition model was implemented between a health system population health management office and a primary care organization. Findings/conclusions: An effective care transitions model is stronger with collaboration among core members of a patient's care team, including a nurse care manager and a primary care provider. Ongoing quality improvement is necessary to gain efficiencies and effectiveness of such a model. Implications for Case Management Practice: Care managers are integral in coordinating effective transitions. Care management practice includes transition of care standards that are associated with improved outcomes for patients at high risk for readmission. Interventions inclusive of medication reconciliation, identification and addressing of health-related social needs, review of discharge instructions, and coordinated follow-up are important factors that impact patient outcomes. Patients and their health system care teams benefit from the role of a care manager when there is a collaborative, coordinated, and timely approach to hospital follow-up. Competing Interests: The authors report no conflicts of interest. (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)
Databáze:	MEDLINE
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