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Challenges Running a Program

Challenges Working with Patients


Connecting with Families: Turning Interest into Action

University of Illinois at Chicago’s Division of Specialized Care for Children (DSCC) has a regional office in Peoria, a city that is home to a well-known children’s hospital that cares for many children eligible for DSCC’s programs. Many of these children are referred to DSCC for assistance but often not until the child is older. DSCC’s care coordination teams believe it is vital that these children are referred to our programs as soon as soon after birth as possible, especially those with critical cardiac conditions. DSCC’s Peoria staff had developed relationships with the hospital’s nurses and s...


Huddling to Improve Teamwork

In DSCC’s Mokena Regional Office, each Care Coordinator is paired with a Program Coordinator Assistant to work as a team to meet a child and family’s needs. A Care Coordinator is a DSCC staff person who is a nurse, social worker, speech pathologist or audiologist. A Program Coordinator Assistant (PCA) is often a family’s first contact with DSCC. The PCA takes referrals, discusses the child’s needs and sends the application to families. The PCA also determines financial eligibility and updates this information periodically.

The Care Coordinator and PCAs’ individual responsibilities often are co...


Meds to Bed Program: A Medication Concierge Service

Tamblyn and colleagues found that nearly a third of patients fail to fill first-time prescriptions.1 Other studies have found that e-prescriptions are 65% more likely to be left abandoned at a retail pharmacy by patients than hand-written prescriptions. 3 Mount Sinai Hospital (MSH) recognizes that the issue of medication adherence is challenging. MSH strives to become the national model for the delivery of urban healthcare and develops innovative and effective ways to accomplish its mission.

In the communities served by MSH, the percentage of citizens living below the poverty line...


Calvert CARES Program Reducing Readmissions: It’s All About Relationship

CalvertHealth Medical Center (CHMC) was challenged with developing an innovative plan to address high utilizer recidivism in the ED and inpatient settings. Early success with the Transitions to Home Program resulted in readmission targets being significantly decreased. To identify resource access gaps, CHMC called on its “village” (local health care coalition and their case management team of acute care and emergency department nurses and social workers) to identify opportunities for program enhancement by using a SWOT analysis. Medication and medical supply affordability, transportation access and other s...


Building a Care Coordination Program: Addressing Determinants of Health and Well-being

In 2013, Medical Center Health System, located in Odessa, Texas, embarked on a journey to create a healthier community. We knew we had a long way to go. Our county health rankings weren’t favorable according to the County Health Rankings from the Robert Wood Johnson Foundation, and we didn’t yet have a department at our hospital to address our community’s many health needs. We knew we wanted to approach the issues from the community angle but also from the hospital perspective. Our hospital understood that to build a “Culture of Health” we needed to be innovative and think beyond the traditional four...


Tackling Pneumonia Readmissions through Standardizing Processes

We, at Baptist Memorial Hospital, have been focusing on readmissions for quite some time but for the last two years, we received the readmissions penalty. We’re higher than the national average for pneumonia readmissions rates.


State Policy as an Opportunity to Evaluate Current Discharge Processes

Effective Jan. 1, 2016, Indiana enacted the Caregiver Advise, Record, and Enable Act, or the CARE Act. The CARE Act requires hospitals to offer each admitted patient who will be discharged home an opportunity to: (1) identify a lay caregiver, (2) communicate with the lay caregiver regarding discharge and (3) offer education and training to the lay caregiver to ensure he or she understands how to care for the patient post-discharge, among other things. This required Riverview Health to evaluate its current processes and implement strategies to ensure compliance with the CARE Act.


Heart Failure Readmissions: Pinpoint the Problem, Improve the Process

In 2008, Mary Washington Hospital (MWH) was ranked first in the state for having the worst 30-day Heart Failure (HF) All-Cause readmission rate. Inconsistent with our mission for improving the health status of the people in our community, MWH undertook efforts to reduce HF readmissions. With administrative support, a registered nurse (now the HF Program Coordinator) began taking steps to identify opportunities surrounding HF readmissions. From detailed chart review, it was discovered that the opportunities were multi-faceted and required an organized, comprehensive approach.


Commitment to Warm Hand-Offs Amongst a Complex System

It can be difficult to ensure patients receive a warm hand-off when there are many moving parts in a complex system. Sakakawea Medical Center and Coal Country Community Health Center worked to improve their continuous care model. This model transitioned patients from the medical center to the clinic with a warm hand-off to allow for continuity of care.


Identify and prioritize transitional care program patients

Illinois Valley Community Hospital set a goal to reduce its readmissions rate for patients diagnosed with congestive heart failure, COPD and pneumonia. This rate tends to run slightly higher than the overall hospital readmissions rate (1 percent). Medicare also focuses on congestive heart failure, COPD and pneumonia for reimbursement.


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