STORIES by TOPIC
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- Lodi Memorial focused on readmission types that they could reasonably affect when setting goals.
- Marin General presents post-discharge coaching as part of a patient’s care plan rather than as an optional service requiring consent.
- Marin General’s program had a rocky start because of competing hospital initiatives that overwhelmed staff.
- VA Palo Alto created a patient-friendly After Hospital Care Plan tailored to their patients’ needs and integrated with their EMR.
- St. Rose makes a follow-up call after a patient’s doctor appointment. This makes patients accountable for going and taking notes.
- Lodi Memorial simplified BOOST’s risk assessment tool to meet the specific needs of their hospital and patients.
- Lodi Memorial trained SNF staff on how to speak with resident families to prevent unnecessary readmissions.
- St. Mary’s hospital developed a structured discharge process to help care teams prepare patients for discharge.
- St. Mary’s identifies a patient’s non-hospital care team of family, friends, and hired help—then works with them to develop a care plan.
- At St. Mary’s, the president and all directors make daily rounds to speak with patients individually and solve issues on the spot.