The McNemar Test determined that there was a statistically significant difference between the readmission rates of patients not enrolled in the TOC program and those that were enrolled. The readmission rate for those not enrolled was 26% and for those...
Our hospital developed a multidisciplinary team of nurses, social workers, advanced practice providers, and physician navigators to assist patients after they are discharged home from the acute-care setting. This team uses an interdisciplinary approach, connecting with stakeholders across the patient’s...
The outcome was the development of three sets of patient empowerment and engagement tools: to manage heart failure, to learn more about heart failure, and to connect with others for support with heart failure. As an ongoing effort, IMPLEMENT-HF is...
Attendees who participate in this session will learn: -Methods to identify high-risk of readmission population -Deployment strategies to further strengthen care coordination of high-risk of readmission population in an effort to reduce readmission -Primary Care Provider workflows to ensure 7-day...
Describe the process and results of a 4-week health promotion program implemented within a Fellowship of Churches with overweight or obese African American adult congregants using Dr. Carolyn Tucker’s Health Smart Behavior Program. Tool: Health-Smart Behavior Program by Dr. Carolyn...
Review of the process to create a dashboard (work ongoing) identifying which readmission-reducing countermeasures are available and in use at which hospital sites in the Cleveland Clinic system, and delineating the effectiveness of each countermeasure at reducing readmissions. Patients are...
The Hypertension CPG was published in 2020. To date, dissemination and implementation have occurred in 171 VA Medical Centers and 1298 healthcare facilities across the US. A range of training and resources are available to support the implementation of best...
126 patient encounters were evaluated. The most frequent Drivers of Utilization were Chronic Unstable Baseline, Unaddressed/Inadequately Managed Behavioral Health, and Unaddressed Goals of Care. Most frequent action items: medication reconciliation and subspecialist follow-up. Next steps: Create a process to evaluate...
First in VHA SUD care team, a teratogenic time-out for the safe prescribing process, partnering with experts to create successful pathway for pregnant to ensure mental health needs are met, and more. Continue to develop new ways to participate in...