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pcmh.ahrq.gov/sites/default/files/attachments/Roles%20of%20PCMHs%20And%20ACOs%20in%20Coordinating%20Patient%20Care.pdf
December 01, 2010 - to coordinate care effectively as part of their routine clinical
work. … Create and update a proactive plan of care
2
: Establish and maintain a plan of care,
jointly created … directly engaging clinical care providers. … to develop and update a plan of care. … Additionally, ACOs can facilitate transitions and align resources to meet the clinical
care and care
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pcmh.ahrq.gov/sites/default/files/attachments/Vermont_020413comp.pdf
January 01, 2013 - The teams meet at least monthly to review data and plan data-guided improvement. … The program aims to reach 200
practices, or 90 percent of the primary care practices in the State, by … Once the practice has defined
its goals and developed an improvement plan, the facilitator provides … The practice works on the clinical content—for example, asthma guidelines—and the
10
facilitator … or physician hospital organizations.
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pcmh.ahrq.gov/sites/default/files/wysiwyg/news/events/conference/2011/naylor/naylor.pptx
January 01, 2011 - www.transitionalcare.info
Across Reported RCTs, TCM has…
Increased time to first readmission or … Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial … Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial … Journal of Evaluation in Clinical Practice. doi: 10.1111/j.1365-2753.2011.01659.x.
www.transitionalcare.info … www.transitionalcare.info
Implementation Progress
Aetna – expansion of TCM proposed as part of Aetna’s Strategic Plan
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pcmh.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/hp/Child_Med_Eng_HP51_2155a.pdf
October 01, 2020 - This includes care your child got in
person, by phone, or by video. … In the last 6 months, did your child have an
illness, injury, or condition that needed
care right away … she get health
care in person, by phone, or by video? … Is your child able to talk with doctors
about his or her health care? … Do not include dental visits or care
your child got when he or she stayed overnight
in a hospital.
-
pcmh.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2023qdr-meps-methods.pdf
December 01, 2023 - care, dental care, or
prescription medicines due to financial or insurance
reasons” with: “Composite … measure: People unable to
get or delayed in getting needed medical care, dental
care, or prescription … for an illness, injury, or condition in the last 12
months who sometimes or never got care as soon … health condition
Core
Adults who had a doctor’s office or clinic visit in the last 12 months whose … needed care right away for an illness, injury, or condition in the last
12 months who sometimes or never
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pcmh.ahrq.gov/page/cognitive-task-analysis-methods-improve-patient-centered-medical-home-models-understanding-and
March 01, 2013 - Broadly speaking, CTA can be used to better understand the macrocognition in any clinical or organizational … Clinical Assessment Skills of Experienced Neonatal Intensive Care Nurses. … What is a good plan? Cultural variations in expert planners’ concepts of plan quality. … Clinical Assessment Skills of Experienced Neonatal Intensive Care Nurses. … Int J Qual Health Care 2009;21(1):66–75. Rasmussen LJ, Sieck WR, Smart P. What is a good plan?
-
pcmh.ahrq.gov/news/newsletters/e-newsletter/895.html
January 01, 2024 - the work of Thomas McGinn, M.D., M.P.H., who has developed clinical prediction rules or decision aids … sites in 24 states, credits AHRQ with “truly getting it from the beginning” and understanding why clinical … Patient Safety Network (PSNet) now allow users to search patient safety research publications in eight clinical … areas ranging from COVID-19 to nurse care to palliative care. … Plan selection, enrollee risk, and health spending on the Patient Protection and Affordable Care Act
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pcmh.ahrq.gov/sites/default/files/wysiwyg/topics/dx-safety-mental-health-bmjqs.pdf
April 15, 2024 - We also do not cover the topic of overdiagnosis (when
a condition is diagnosed that would not otherwise … only inappropriate psychiatric
diagnosis, but also mistaking a physical illness for a
psychiatric condition … wrong diagnosis Compare recent clinical documentation or
clinician-reported diagnosis to the outcome … Participants in the ‘de-biasing’ condition
gave more accurate diagnostic impressions and
made fewer … Influence of psychiatric
or social backgrounds on clinical decision making: a
randomized, controlled
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy2/Strat2_Implement_Hndbook_508.pdf
April 30, 2013 - Assess family presence or visitation policies
The family cannot be partners of the health care team … by giving them information about the patient’s
condition and next steps regularly throughout the hospital … of care, such as their skills in diagnosing,
treating, and obtaining positive clinical outcomes. … Plan the clinician training. … Train staff
Staff training should include physicians, nurses, and other clinical providers.
-
pcmh.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2021qdr-mepsmethods.pdf
December 01, 2021 - who were unable to get or
delayed in getting needed medical care, dental care, or
prescription medicines … delayed in getting
needed medical care, dental care, or prescription medicines
due to financial or … for an illness, injury, or condition in the last
12 months who sometimes or never got care as soon … health condition
Core
Adults who had a doctor's office or clinic visit in the last 12 months whose … needed care right away for an illness, injury, or condition in the
last 12 months who sometimes or
-
pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/medication/tool_safe-mgso4.docx
May 30, 2013 - Magnesium toxicity is a clinical diagnosis, and serum levels do not always correlate with clinical signs … Situational awareness refers to all staff caring for the patient—
· knowing what the patient’s plan is … maternal status, and knowing the plan for a timely response to prevent further deterioration. … discuss plan of care if patient fails to respond to initial measures. … Use of transition communication techniques assures a shared mental model of plan of care and perceived
-
pcmh.ahrq.gov/sites/default/files/wysiwyg/data/SyH-DR-PUF-Summary-Statistics-Medicare-Outpatient-Weighted.pdf
September 26, 2023 - 1.00 60.00 1.93 16.53
PERSON_WGHT Person Weight 11,097,026 0 1.00 1,000.00 15.52 10.18
PLAN_PMT_AMT Plan … discontinued care. 395,523 0.23 165,806,533 96.26
08: Discharged/transferred to home under care of … /transferred/referred to another institution for outpatient services as specified
by the discharge plan … /referred to this institution for outpatient services as specified by
the discharge plan of care (eff … . 9/2001) (discontinued eff. 10/1/2005)
7,826 0.00 172,131,768 99.93
81: Discharged to home or self-care
-
pcmh.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2016-materials/teamstepps-monthly-webinar-march2016.pptx
January 01, 2016 - agenda focus on four areas:
Patient safety
Patient satisfaction/experience
Employee satisfaction/morale
Clinical … daily approach
Critical care positions are assigned based on:
Society of Critical Care Medicine Priority … Crit Care Med 1999 Mar; 27(3) 633-638
TEAMSTEPPS 05.2
Mod 1 05.2 Page ‹#›
TeamSTEPPS®
OR to ICU … ›
24
Surgical APGAR
Simple score based on blood loss, heart rate, and blood pressure
Grades the condition … Slide ‹#›
35
Clinical Results
Decrease in the overall number of PACU boarders
Less interruptions
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/lep/handouts/stafftrainhandouts_all.pdf
September 01, 2012 - larger group (e.g., senior leaders, including patient safety officers, leaders of the units
where you plan … been held liable for LEP patient safety events caused by poor patient
comprehension of their medical condition … make medical interpretation errors, and these
errors are significantly more likely to have potential clinical … Errors in medical interpretation and their potential clinical
consequences in pediatric encounters. … How do you plan to use what you learned in this training?
-
pcmh.ahrq.gov/teamstepps-program/curriculum/situation/tools/index.html
June 01, 2023 - Know and understand the treatment plan. … Inform team members when the plan or team composition has changed. … support teams by:
Leading to a mutual understanding of problems, goals, team strategies, patients’ condition … , and plan of care. … If someone holds back information or is ignored by other team members, patient care can be compromised
-
pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/lep/handouts/trainershandouts_all.pdf
September 01, 2012 - larger group (e.g., senior leaders, including patient safety officers, leaders of the units
where you plan … been held liable for LEP patient safety events caused by poor patient
comprehension of their medical condition … make medical interpretation errors, and these
errors are significantly more likely to have potential clinical … Errors in medical interpretation and their potential clinical
consequences in pediatric encounters. … How do you plan to use what you learned in this training?
-
pcmh.ahrq.gov/sites/default/files/wysiwyg/chsp/CHSP-accomplishments-report-2021.pdf
January 01, 2021 - of oncology care affects the use of PCOR-based processes and related
clinical and economic outcomes … one or more hospitals and one or more
primary or multispecialty care physician practices, (2) two or … ),
• Related clinical outcomes,
• Cost of care, and
• Patient and family self-reports about the quality … factors for patients covered by a particular health plan rather than
community-level measures that … cardiovascular and
comorbid mental health conditions, as well as those with at least three Hierarchical Condition
-
pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/implementing-guide.pdf
March 01, 2017 - clinical and cultural interventions. … improve resident safety, clinical
outcomes, and safety culture. … Clinical Interventions
Improvements in clinical care of residents begin with understanding the appropriate … clinical indications
for indwelling urinary catheter use. … or dementia
• Resident and/or family request
Use Regular Assessments
Review the clinical indications
-
pcmh.ahrq.gov/hai/cauti-tools/archived-webinars/cauti-sustainability-slides.html
December 01, 2017 - security, often while unaware of some potential danger, defect, or the like; self-satisfaction or smug … satisfaction with an existing situation, condition, etc. … process by reassessing and making it current
Slide 25
PDSA Cycles Must Be:
Active:
Quickly plan … Slide 50
Team Design
Physician Champion
Infection Prevention
Frontline staff/Champions
Clinical … Patient Safety Committee Rounds:
Included how many patients have urinary catheters
What is the plan
-
pcmh.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/state-of-science.pdf
April 02, 2020 - Availability of clinical data that provide a longitudinal picture across care
settings is essential … and that
corresponding clinical data across the care continuum are essential to inform measurement. … a few specific diagnoses or care processes. … for that condition (magnetic resonance imaging on all patients with dizziness in primary or emergent … action plan.