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Amanda Hulletoffline

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Transitioning Patients From the Hospital Back to the Community
August 23, 2019
Implementing a Care Transitions Program to Reduce Readmissions
April 13, 2019
Implementing Safeguards in the Patient Care Home Environment
April 13, 2019
Calvert CARES Program Reducing Readmissions: It’s All About Relationship
February 11, 2019
Bridging Cardiac Rehab and Patient-Centered Care
August 7, 2018
Rolling Out the 4Ms for Age-Friendly Care Across the Care Continuum
July 24, 2018
Structuring Medicare Wellness Exams and Geriatric Consultations Around the “4Ms”
July 13, 2018
Finding Out What Matters to Older Patients: A Conversation Guide
July 11, 2018
Referral Process Improves Cardiac Rehabilitation Participation Rates
June 15, 2018
Deploying the 4Ms to Improve Outcomes and Health Experiences for Older Adults
May 14, 2018
Saint Alphonsus is Becoming Age Friendly
May 14, 2018
Emergency Department Partners with Community Volunteer Dental Program
April 19, 2018
Improving Patient Recovery Through Cardiac Rehab
March 30, 2018
Reducing Rural Transportation Barriers
March 20, 2018
Connecting with Families: Turning Interest into Action
November 13, 2017
Huddling to Improve Teamwork
November 13, 2017
Meds to Bed Program: A Medication Concierge Service
August 25, 2017
Building a Care Coordination Program: Addressing Determinants of Health and Well-being
June 22, 2017
Tackling Pneumonia Readmissions through Standardizing Processes
June 6, 2017
State Policy as an Opportunity to Evaluate Current Discharge Processes
May 23, 2017
Heart Failure Readmissions: Pinpoint the Problem, Improve the Process
March 3, 2017
Commitment to Warm Hand-Offs Among a Complex System
February 16, 2017
Identify and prioritize transitional care program patients
September 20, 2016
Make changes to routine practices
June 20, 2016
Implement admission, discharge, and transfer notifications in real time
April 28, 2016
Medicare beneficiaries take control of diabetes self-management
April 22, 2016
Reverse adverse drug events by establishing processes
April 12, 2016
Drive facility interventions from data
April 5, 2016
Assisting patients in creating a Quality-of-Life Care Plan
March 16, 2016
Design targeted hospital units to communicate consistently with patients
March 7, 2016
Step into your Sunday Shoes to decrease heart failure readmissions
March 3, 2016
Improving bidirectional communication between the emergency department and post-acute care facilities
February 22, 2016
Generate dialogue and implement changes by assembling a coalition
February 18, 2016
Creating improved medical management in community Skilled Nursing Facilities
February 11, 2016
Settle patients into their new environment with a handoff tool
February 2, 2016
Improving care for children with medical complexity
January 19, 2016
Building a care transitions model with a CCTP for high risk patients
January 8, 2016
Connect and check-in with patients after discharge
January 6, 2016
Easing the discharge process through a comprehensive readmissions reduction plan
January 6, 2016
Educating physicians to reduce readmissions in a rural setting
December 17, 2015
A health system approach to opioid safety
December 17, 2015
Reducing emergency department overuse with the E.C.H.O Program (Emergency Care Helping Others)
December 1, 2015
Patient centered approach to reducing readmissions
November 18, 2015
Establishing bedside delivery of high-risk medications following an adverse event
November 6, 2015
[UCSF] Sample team newsletter
September 3, 2015
[UCSF] Sample emails to SNFs
August 11, 2015
The value of making a connection with the partner SNF
August 11, 2015
Knowing when to start goals of care conversations
August 7, 2015
Using patient stories to gain understanding and initiate org change
August 7, 2015
Employing pharmacists and pharm techs to tackle med rec and education
June 24, 2015
Coaching in chunks
June 23, 2015
Using experts to get buy-in with executives
June 23, 2015
From patient care boards to patient communication boards
June 22, 2015
The power of a little red notebook
June 22, 2015
Creating a patient discharge advocate role
June 22, 2015
Standardizing review processes with SNFs
June 22, 2015
Doing complex risk assessment with a few questions and your gut
June 22, 2015
Supplementing hospital staff with community resources
June 22, 2015
Hiring from your community to better connect with patients
June 22, 2015
Creating a clinic can lower readmissions rates while saving time
June 22, 2015
Using ‘gut feelings’ to identify the right patients for enrollment
June 22, 2015
Taking home visits out of the home
June 22, 2015
An unexpected cause of early-dosing of medications
June 22, 2015
Teaching to fish: giving patients tools to put education into practice
June 21, 2015
Building multi-disciplinary discharge instructions
June 21, 2015
Why I say “water pill” instead of “Lasix” or “diuretics”
June 21, 2015
Reframing bedside rounds around discharge planning
June 21, 2015
Putting last medication dose information in discharge instructions
June 21, 2015
The power of SNF-to-hospital case reviews
June 21, 2015
Reaching your goals by carefully expanding your scope
June 20, 2015
Looking at your numbers to know what you can affect
June 20, 2015
Embedding post-discharge care into patient care plans
June 20, 2015
Beware competing hospital initiatives when launching your program
June 20, 2015
Creating clear and helpful discharge instructions
June 20, 2015
Motivating patients with multiple follow up phone calls
June 19, 2015
Balancing rigor and efficiency when it comes to risk assessment
June 19, 2015
Avoiding panic when SNFs notify family of a patient’s change in condition
June 19, 2015
Starting discharge planning on day one
June 19, 2015
Building a patient’s non-clinical care team post-discharge
June 19, 2015
Getting buy-in with the help of administrative rounds
June 19, 2015
Creating day-by-day care plans to improve care and shorten stays
June 19, 2015
Simplifying educational materials for easier understanding
June 19, 2015
Preventing burnout by building a patient’s personal care team
June 19, 2015
Breaking down readmission numbers to get departmental buy-in
June 19, 2015
Helping patients connect their behaviors to symptoms
June 19, 2015
Using a “warm line” to prevent readmissions
June 19, 2015
Giving homeless patients a place to call home
June 19, 2015
Helping patients with everyday problems (not just medical ones)
June 19, 2015
Tackling substance abuse head on
June 19, 2015
The importance of executive leadership in transitions programs
June 19, 2015
Considering social determinants when assessing risk
June 19, 2015
The value of warm handoffs in making patients feel comfortable
June 19, 2015
Self enrollment: an alternative to risk assessment tools
June 19, 2015
Staying on top of community services with quarterly share outs
June 19, 2015
Tailoring tools to older patients
June 19, 2015
Removing redundancies in follow up phone calls
June 19, 2015
Teaching staff how to do Teach-back
June 19, 2015
Keeping medication lists on hand with wallet cards
June 18, 2015
Redesigning patient assessment forms from the frontline
June 18, 2015
Building team identity with branded scrubs
June 18, 2015
Celebrate your patients’ little triumphs—and your own
June 18, 2015
Empowering patients by showing them they’re not alone
June 18, 2015
The benefit of non-clinical roles on a transitions team
June 18, 2015
The importance of transparency in maintaining program buy-in
June 18, 2015
Using visual tools to track readmissions and get the big picture
June 18, 2015
Motivating staff for a strong transition team
June 18, 2015
The benefits of a transitions program with multiple points of view
June 18, 2015
“Don’t:” the four-letter word when coaching patients
June 17, 2015
Building a relationship from hospital to home
June 15, 2015
Developing solutions from the ground up
June 14, 2015
The benefits of a dedicated med rec tech
June 12, 2015
Using personal goals to achieve medical ones
June 12, 2015
Partnering with outpatient providers to identify gaps in patient care
June 9, 2015
Getting patients and PCPs to follow through on follow up appointments
June 9, 2015
Sharing domains of risk with outpatient providers
June 9, 2015
Reframing the program from opt-in to opt-out
June 8, 2015
Facilitating real-time communication with a mobile app
June 5, 2015
Bringing in pharmacists before discharge
June 5, 2015
Adapting risk-assessment tools to find other at-risk patients
June 5, 2015
Timing your follow up calls to have the most impact
June 3, 2015
Letting patients choose their own transition plan
June 3, 2015
The trick to motivation? Using personal goals over medical ones.
June 2, 2015
Working with fewer patients to have a bigger impact
June 2, 2015

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Program Challenges
- Building Commitment for Care Transitions
- Motivating the Team
- Identify Which Patients Need Extra Help
- Coordinating Care Across the Whole Team
- Coordinating with Outpatient Care
- Determining Skills Needed on the Team
- Communicating with Patients
- Making Follow-up Calls or Home Visits
- Limited Resources
Patient and Family Challenges
- Understanding Medication Instructions
- Next Steps After Leaving the Hospital
- Not Receptive to Our Help
- Low Health Literacy
- Social Challenges
- Not Receptive to Home Visits
- Empowering Patients
- Going to Follow-up Appointments
Story Topics
- Effective teamwork
- Establishing a program
- Organizational buy-in
- After-hospital care
- Patient engagement
- Identifying causes of readmission
- Measuring and improving
- Using resources effectively
- Cardiac Rehab
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