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.
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
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
The development of a comprehensive chronic disease management program can significantly improve a patient’s quality of life.
Design targeted hospital units to communicate consistently with patients
Step into your Sunday Shoes to decrease heart failure readmissions
By standardizing verbal and written transitions processes, UW ensures accurate clinical information is exchanged.
Improving bidirectional communication between the emergency department and post-acute care facilities