This article describes some challenges of care transitions, reviews best practice strategies, provides an example of systems-based improvements at a health care system in Wisconsin, and outlines some lessons learned.
This brief, made possible with support from the West Health Policy Center, highlights promising community-based nutrition practices for older adults used by Medicaid health plans, including: (1) investing in staff with nutrition expertise; (2) using assessment data to target nutrition-related interventions; (3) replicating best practices from other member populations; and (4) leveraging community-based resources.
Delirium is common among seniors discharged from the emergency department (ED) and associated with increased risk of mortality. Prior research has addressed mortality associated with seniors discharged from the ED with delirium, however has generally relied on data from one or a small number of institutions and at single time points.
Home-based primary care (HBPC) is a multidisciplinary, ongoing care strategy that can provide cost-effective, in-home treatment to meet the needs of the approximately four million homebound, medically complex seniors in the U.S. Because there is no single model of HBPC that can be adopted across all types of health organizations and U.S. geographic regions, we conducted a six-site HBPC practice assessment to better understand different operation structures, common challenges, and approaches to delivering HBPC.
This review article describes the research evidence for developing a better system of care for high-cost, high-risk patients. It reviews the evidence that home-centered care and integration of health care with social services are the cornerstones of a more humane and efficient system.
Abstracts 2019 Norman, GJ, Kent, T, Kinosian, B, Kronick, R. (2019). Feasibility of shared savings models for small home-based primary care practices. Journal of the American Geriatrics Society, Vol 67 (Suppl S1), S171-172. Norman, GJ, Slaboda, JC. (2019). Family Caregivers’ Perceptions of How the Health System and Community Support Older Adults. Aging in America, Annual… Read more »
The study objective was to explore emergency physicians’ (EP) awareness, willingness, and prior experience regarding transitioning patients to home-based healthcare following emergency department (ED) evaluation and treatment; and to explore patient selection criteria, processes, and services that would facilitate use of home-based healthcare as an alternative to hospitalization.
West Health has recognized that home-centered care can be a focal point for seniors, offering the option for effective care provided within the safety and comfort of home. The study described in this paper was designed in collaboration with the UCSD Department of Emergency Medicine in order to explore the possibility of providing home-based acute care options.
