Project BOOST Implementation: Lessons Learned

Williams, Mark; Jing, Li; Hansen, Luke O.; Forth, Victoria E.; Budnitz, Tina; Greenwald, Jeffrey L.; Howell, Eric; Halasyamani, Lakshmi; Vidyarthi, Arpana R.; Coleman, Eric A.

doi:10.14423/smj.0000000000000140

Cited by 60 publications

(50 citation statements)

References 14 publications

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“…25,[37][38][39] In some programs, follow-up calls were intended to ensure or improve continuity of care transitions after hospitalization, to improve medication adherence, to increase adherence for follow-up appointments with primary care providers, 40 and to reduce rehospitalization. 18,41 In many programs, the first call was to be made within 48 to 72 hours, 17,20,28,34,42 as per national organization guidelines, 1 or based on performance metric recommendations. 43,44 A common feature was to make regular follow-up calls for up to 30 days after discharge.…”

Section: Telephone Follow-upmentioning

confidence: 99%

“…Postdischarge plan and adjustments since discharge 20 Problems or issues that emerged since discharge 20 Deliver Medical management as needed for HF and comorbid conditions 27 Coordinated care 27 General telephone outreach to patient (components not specified) 21,33 Discuss Answers to patient questions 28 Issues related to transition to home 28 Document In patient-centered health record (to promote interdisciplinary communication) 23 On a discharge checklist focused on critical activities (eg, medication reconciliation, patient education) 23 Data coordination efforts and expectations Medicare patients, patient engagement was enhanced by the availability of data, the coordination of data flow, and a patient-centered health record that fostered interdisciplinary communication.…”

Section: Confirmmentioning

confidence: 99%

See 1 more Smart Citation

Transitions of Care in Heart Failure

Albert¹,

Barnason²,

Deswal³

et al. 2015

Circ: Heart Failure

218

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In patients with heart failure (HF), use of 30-day rehospitalization as a healthcare metric and increased pressure to provide value-based care compel healthcare providers to improve efficiency and to use an integrated care approach. Transition programs are being used to achieve goals. Transition of care in the context of HF management refers to individual interventions and programs with multiple activities that are designed to improve shifts or transitions from one setting to the next, most often from hospital to home. As transitional care programs become the new normal for patients with chronic HF, it is important to understand the current state of the science of transitional care, as discussed in the available research literature. Of transitional care reports, there was much heterogeneity in research designs, methods, study aims, and program targets, or they were not well described. Often, programs used bundled interventions, making it difficult to discuss the efficiency and effectiveness of specific interventions. Thus, further HF transition care research is needed to ensure best practices related to economically and clinically effective and feasible transition interventions that can be broadly applicable. This statement provides an overview of the complexity of HF management and includes patient, hospital, and healthcare provider barriers to understanding end points that best reflect clinical benefits and to achieving optimal clinical outcomes. The statement describes transitional care interventions and outcomes and discusses implications and recommendations for research and clinical practice to enhance patient-centered outcomes.

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Section: Telephone Follow-upmentioning

confidence: 99%

Section: Confirmmentioning

confidence: 99%

Transitions of Care in Heart Failure

Albert¹,

Barnason²,

Deswal³

et al. 2015

Circ: Heart Failure

218

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show abstract

“…Evidence-based models for safe care transitions can support better systems for end-of-life care. 31,32 Third, productive systemic and financing reforms can be enacted. Misaligned financial incentives work against dying patients' choices, interests, and safety.…”

Section: Lessons From 4 0 Ye Ars Of Workmentioning

confidence: 99%

Forty Years of Work on End-of-Life Care — From Patients' Rights to Systemic Reform

Wolf¹,

Berlinger

Jennings³

2015

N Engl J Med

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“…Yet, in the context of high patient volumes and competing priorities, clinicians often postpone discharge planning until they perceive a patient's discharge is imminent. “Discharge bundles,” designed to improve the safety of hospital discharge, such as those developed by Project BOOST (Better Outcomes by Optimizing Safe Transitions) or Project RED (Re‐Engineered Discharge), are not designed to help providers determine when a patient might be approaching discharge . Early identification of a patient's probable discharge date can provide vital information to inpatient and outpatient teams as they establish comprehensive discharge plans.…”

mentioning

confidence: 99%