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Transitional Care/After Care

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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.

Transition Planning for Youth with Special Health Care Needs

June 6, 2005 | Journal Article

Children with special health care needs are dependent on uninterrupted medical care for their health and well-being. Almost 13 percent of children in the U.S. are classified as such and they account for a disproportionate share of health care expend ...

Access to Care for Youth with Special Health Care Needs in the Transition to Adulthood

July 1, 2008 | Journal Article

Youth with special needs face numerous issues when transitioning to the adult health system. A survey of 77 youth showed that too many lacked a usual source of care, and were either uninsured or had experienced an insurance gap.

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.

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

April 18, 2011 | Program Result 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.

Mapping the Innovation in Correctional Health Care Service Delivery in New York City

April 1, 2008 | 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.

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

June 28, 2010 | Program Result 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.

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.

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