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Improving Care Transitions
Preventing Avoidable Readmissions Programming
In-Person Training
November 6, 2014
Readmissions Summit
- In collaboration with the Massachusetts Hospital Association
- Keynote Speaker Presentations
- Presentations by Cape Cod Healthcare, Cooley Dickinson VNA & Hospice, Lawrence General Hospital, Massachusetts Senior Care Foundation, MetroWest Medical Center, Partners and the Office of the National Coordinator for Health Information Technology
June 25, 2014
Learning and Action Network, Improving Care Transitions and Reducing Avoidable Readmissions Breakout Sessions
- In collaboration with Masspro
- Presentations by Beth Israel Deaconess Medical Center, Boston Children’s Hospital and Cambridge Health Alliance
September 12, 2013
Learning and Action Network, Reducing Readmissions Breakout Sessions
- In collaboration with Masspro
- Presentations by BayPath Elder Services, Cape Cod Hospital, Mass Home Care, Massachusetts Senior Care Foundation, Mercy Medical Center, Southboro Medical Group, Southcoast Health System, South Shore Hospital, Welch Healthcare & Retirement Group
October 30, 2012
Learning and Action Network, Following the Patient’s Healthcare Journey
- In collaboration with Masspro
- Agenda
Presentations
April 23, 2012
STate Action on Avoidable Rehospitalizations (STAAR) Learning Session
- In collaboration with the Massachusetts Hospital Association, the Department of Public Health and the Massachusetts Medical Society
- Presentations by Beaumont Rehabilitation and Skilled Nursing Center, Beth Israel Deaconess Medical Center, Cambridge Health Alliance, Commonwealth Care Alliance, Cooley Dickinson Hospital, Elder Services of Merrimack Valley, Emerson Hospital, Hebrew SeniorLife, Holyoke Medical Center, Home Health VNA, Institute for Healthcare Improvement, Iowa Health System, Lawrence General Hospital, Life Care Center of West Bridgewater, Maristhill Nursing and Rehab Center, Saints Medical Center, Steward Health Care System and Sturdy Memorial Hospital
October 11 – 12, 2011
STAAR Learning Session
- In collaboration with the Massachusetts Hospital Association, the Department of Public Health and the Massachusetts Medical Society
- Presentations by Ballit Health, Baystate Medical Center, Beth Israel Deaconess Medical Center, Cape Cod Hospital, Hallmark Health, Institute for Healthcare Improvement, Massachusetts General Hospital, Massachusetts Senior Care Foundation, MetroWest HomeCare & Hospice, MetroWest Medical Center, Northeast Hospital, Saints Medical Center, South Shore Hospital, St. Anne’s Hospital, Sturdy Memorial Hospital, UMass Medical School and Visiting Nurse Association of Boston & Affiliates
February 2 – 3, 2011
STAAR Learning Session
- In collaboration with the Massachusetts Hospital Association, the Department of Public Health and the Massachusetts Medical Society
- Presentations by Baystate Medical Center, Institute for Healthcare Improvement, Lahey Health, MetroWest Medical Center, Newton Wellesley Hospital, Northeast Hospital, North Shore Medical Center, South Shore Hospital and VA Healthcare
April 2009
Massachusetts Care Transitions Forum and Care Transitions Seminar
- Presentations by Massachusetts Association of Health Plans and United Hospital Fund
Webinars
April 29, 2014
Improving Care Transitions from the Skilled Nursing Facility to Hospital ED: A Hospital-Skilled Nursing Facility Partnership to Reduce Avoidable Admissions
- In collaboration with Masspro and the Massachusetts Hospital Association
- Presentation by Hallmark Health System Improving Care Transitions from the Hospital to Skilled Nursing Facility Setting: A team approach to implementing INTERACT Tools
- In collaboration with Masspro and the Massachusetts Hospital Association
- Presentations by Hallmark Health System, Massachusetts Senior Care Foundation and Welch Healthcare and Retirement
March 27, 2014
Improving Care Transitions from the Hospital to Skilled Nursing Facility Setting: A team approach to implementing INTERACT Tools
- In collaboration with Masspro and the Massachusetts Hospital Association
- Presentations by Hallmark Health System, Massachusetts Senior Care Foundation and Welch Healthcare and Retirement Group
Calls
April 12, 2013
Linking Office Practices with STAAR (STate Action on Avoidable Rehospitalizations) Cross Continuum Teams
- Presentations by Baystate Medical Center and Holyoke Health Center
March 8, 2013
Common Strategies for Improving Post-Acute Care in Skilled Nursing Facilities
- Presentation by Partners Healthcare
December 17, 2012
Advance Care Planning & Massachusetts Medical Orders for Life-Sustaining Treatment
- Presentation from Beverly Hospital & Addison Gilbert Hospital
September 14, 2012
Readmissions Activity in Massachusetts Hospital Engagement Network
- Presentations by Hallmark Health System, Lowell General Hospital and Sturdy Memorial Hospital – Reducing Readmissions
July 24, 2012
Readmissions Activity in Massachusetts Hospital Engagement Network
- Presentation by Cape Cod Healthcare – Using Data to Drive Change
Improving Care Transitions
Engaging the Voice of the Patient in Improving the Hospital Discharge
The Massachusetts Coalition for the Prevention of Medical Errors joined Health Care For All to bring the patient and family voice to improving the hospital discharge process in order to decrease preventable readmissions and improve the patient’s and family’s experience. The goal was a consumer-centered discharge process that ensures a full understanding of the patient’s post-discharge needs and concerns shared by patients (and their family caregivers) and hospital staff managing the discharge. We sought to increase the capacity of Massachusetts’ hospitals to listen to consumers, as well as to increase the level of patient engagement with
hospitals, as they worked together to design this consumer-centered discharge process.
Through the financial support of the Picker Institute, this project worked to:
- Increase the understanding of the concerns of patients and families through engagement and communication strategies, including the hospital Patient Family Advisory Councils and patient and family involvement in the hospital’s improvement team;
- Develop best practices for the discharge process in response to the needs of patients and caregivers; and encourage their adoption;
- Improve communication between patients and providers prior to the hospital discharge by offering models of effective listening and responsiveness;
- Facilitate smooth discharges from hospitals to home, and reduce the number of preventable readmissions;
In-Person Training
May 2012
Engaging Patients and Families in Improving the Hospital Discharge
- Presentation by Health Care for All and the Massachusetts Coalition for the Prevention of Medical Errors
May 5, 2011
Real-Time Patient and Family Centered Handover Communication: Personal Health Journal
- Presentation by Lahey Health
Webinars
February 16, 2012
Always Events Learning Network: Critical Elements of Communication
- Presentation by Dartmouth-Hitchcock Medical Center, Massachusetts General Hospital, Northeast Valley Health Corporation, University of Arizona and University of South Florida
October 20, 2011
Always Events Learning Network: Redesigning Discharge
- Presentations by Health Care for All, John Hopkins, Massachusetts Coalition for the Prevention of Medical Errors and SUNY Upstate Medical University
June 2, 2011
Picker Institute Work within STAAR/Patient and Family Advisory Councils
- Presentation by the Massachusetts Coalition for the Prevention of Medical Errors
May 19, 2010
LifeBox Collaborative/ Patient and Family Advisory Councils
- Presentation by the Massachusetts Coalition for the Prevention of Medical Errors and The Schwartz Center for Compassionate Healthcare
March 2010
Partnering with the Patient Flow Team to Improve the Patient Discharge Process
- Presentation by Cincinnati Children’s Hospital
March 2010
“Start before you are ready!” Engaging Patients and Families in Redesign
- Presentation by St. Luke’s Hospital
Calls
June 20, 2012
STAAR Coaching Call
- Presentation by Massachusetts Hospital Association
March 21, 2012
STAAR Coaching Call: Patient and Family Advisory Council
- Presentation by Spectrum Health
February 17, 2012
STAAR Coaching Call: Involving Patients and Families to Improve Care Transitions
December 17, 2012
STAAR Coaching Call: Advance Care Planning & Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST)
- Presentation by Beverly Hospital & Addison Gilbert Hospital and MOLST Expansion Director
July 20, 2011
STAAR Coaching Call: Michigan STAAR
- Presentation by the Institute for Healthcare Improvement
May 18, 2011
Interventions to Reduce Acute Care Transfers (INTERACT): Improving Geriatric Care by Reducing Potentially Avoidable Hospitalizations
- Presentation by Massachusetts Senior Care Foundation
April 19, 2011
STAAR Coaching Call: MA Patient-Centered Medical Home Initiative and Managing Transitions
- Presentation by Ballit Health
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