Evidence-Based Interventions
The National Coordinating Center, for the Integrating Care for Populations and Communities (ICPC) Aim, hosted a webinar series to hear about evidenced-based interventions from the intervention developers. While the webinars have ended (1/26/2012), the slides and recordings are available here. Also, links are provided to visit each of the intervention websites.
Care Transitions InterventionSM
Care transition coaches support patients by providing specific tools and teaching self- management skills to ensure patients’ needs are met during the transition from the acute care setting to home.
Project Red (Re-Engineered Discharge)
Standardized discharge intervention. Includes patient education, comprehensive discharge planning, and post-discharge telephone reinforcement.
Bridge Model
Social worker based model focused on patients discharged from acute care. Helps older adults safely transition back into the community through intensive care coordination that starts in the hospital and continues after discharge.
Project Boost (Better Outcomes Older Adults through Safe Transitions)
Toolkit for improving the hospital discharge process. Includes screening/assessment tools, discharge checklist, transition record, teach-back process, risk-specific interventions and written discharge instructions.
Transitional Care Model
Multidisciplinary, comprehensive in-hospital planning and home follow-up. Transitional Care Nurses follow patients from the hospital into the home to provide services designed to streamline plans of care, interrupt patterns of frequent acute hospital and emergency department use, and prevent health status decline.
STAAR (State Action on Avoidable Re-hospitalizations)
The Institute for Healthcare Improvement’s (IHI’s) initiative engages payers, state’s local stakeholders, and patient’s families in all settings.
INTERACT II (Interventions to Reduce Acute Care Transfers)
Toolkit to improve nursing home care by reducing avoidable acute care transfers and hospitalizations. Three types of tools: communication, clinical care paths and advanced care planning.
Home Health Quality Improvement (HHQI) National Campaign-Best Practice Intervention Package (BPIP)
Cross-setting initiative funded by the Centers for Medicare & Medicaid Services. The package includes free online tools and resources designed to unite providers across settings under a shared vision of reducing avoidable hospitalizations and improving medication management
GRACE Model (Geriatric Resources for Assessment and Care of Elders)
Model for primary care and low-income seniors. Developed to optimize health and functional status to keep seniors in the community, and prevent long-term nursing home placement.