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Transitional Care/After Care

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  • Topic: Transitional care/after care
  • Topic: Discharge from health care facility
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  • Medical treatment facilities (7)
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After Hospital Discharge, Does Intensive Case Management Make a Difference?

April 11, 2008 | Program Result Report

The University of Colorado Health Sciences Center examined the effects of five HMO case management programs on patients' compliance with discharge services and use of acute care services.

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.

Quality and Cost Analysis of Nurse Staffing, Discharge Preparation, and Postdischarge Utilization

April 21, 2011 | Journal Article

Investments in nursing care hours reduce hospital readmissions by better preparing patients for discharge.

Expecting Success: Excellence in Cardiac Care

National Program

Expecting Success was a national program aimed at improving the quality of cardiac care while reducing racial, ethnic and language disparities.

Discharge Nurse Position Description

June 4, 2008 | Toolkit

Staff at the University of Texas M.D. Anderson Cancer Center, Houston, Texas, began using an experienced nurse to support the clinical nurses by coordinating discharge activities, serving as a liaison to other team members and ensuring that all aspects of discharge are complete for patients and families.

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.

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.

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

May 11, 2009 | Program Result 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.

Increased Access to Medicaid Had Little Effect on Pregnancy Care or Outcome

January 1, 2001 | Program Result Report

From 1991 to 1996, investigators at Harvard Medical School examined the effects of Medicaid eligibility expansions on a range of maternal and neonatal outcomes in California and South Carolina.

Heart Failure Encounter Form

June 1, 2008 | Toolkit

An off-site, nurse-led heart failure clinic was created to help heart failure patients better control and self-manage their disease post-hospitalization.

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