Huddle stories are ideas for inspiring transitional care solutions, tailored to program and patient needs. Browse through our stories and get inspired to innovate in your organization to improve care coordination.
Medical Center Health System designed and implemented a community health department to build a healthier community.
Building a Care Coordination Program: Addressing Determinants of Health and Well-being
Baptist Memorial Hospital focused on reducing pneumonia readmissions through Kata, a rapid cycle improvement process
Tackling Pneumonia Readmissions through Standardizing Processes
Riverview Health evaluated its processes and implemented strategies to ensure compliance with Indiana’s CARE Act.
State Policy as an Opportunity to Evaluate Current Discharge Processes
Reducing heart failure readmissions required an organized, comprehensive approach at Mary Washington Hospital.
Heart Failure Readmissions: Pinpoint the Problem, Improve the Process
Cheri Basso BSN, RN, CHFN
Sakakawea Medical Center and Coal Country Community Health Center worked to improve their continuous care model to ensure patients consistently received warm hand-offs.
Commitment to Warm Hand-Offs Amongst a Complex System
Illinois Valley Community Hospital implemented a program combining elements of the Coleman and Naylor models.
Identify and prioritize transitional care program patients
Saline Memorial Hospital focused on improving communication, education and daily reporting to reduce readmissions.
Make changes to routine practices
Aledade Delaware ACO developed a population health management tool to more effectively coordinate care.
Implement admission, discharge, and transfer notifications in real time
Medicare beneficiaries take control of diabetes self-management
Care coordination helps lower the incidence of anticoagulant-related adverse events among Centura Health Medicare patients.
Reverse adverse drug events by establishing processes
Greenbriar Community Care Center’s re-hospitalization numbers decreased following data-driven interventions.
Drive facility interventions from data
The Cancer Center at Presbyterian Hospital initiated quality-of-life care planning to improve the patient care transition experience.
Assisting patients in creating a Quality-of-Life Care Plan