Transitions in Care-Quality Improvement Collaborative

TC-QuIC Participating Organizations

Hospitals
The Allen Hospital of NewYork-Presbyterian
Beth Israel Medical Center (Continuum Health Partners)
The Brooklyn Hospital Center (NewYork-Presbyterian)
Coney Island Hospital (New York City Health and Hospitals Corporation)
Franklin Hospital (North Shore-LIJ)
Kings County Hospital Center (New York City Health and Hospitals Corporation)
Lutheran Hospital
Maimonides Medical Center
Metropolitan Hospital Center (New York City Health and Hospitals Corporation)
Montefiore Medical Center
New York Hospital Medical Center Queens
New York Methodist Hospital (NewYork-Presbyterian)
NYU-Langone Medical Center
St. Barnabas Hospital Care Center
St. Luke's-Roosevelt Hospital Center (Continuum Health Partners)

Skilled Nursing Facilities/Rehabilitation Centers
Casa Promesa Residential Health Care Facility
Center for Nursing and Rehabilitation (CenterLight)
Cobble Hill Health Center
Dr. Susan Smith McKinney Care Center (New York City Health and Hospitals Corporation)
Isabella Geriatric Center
Jewish Home Lifecare
Lutheran Hospital (acute rehabilitation unit)
Lutheran-Augustana Skilled Nursing Facility
Orzac Center for Extended Care (North Shore-LIJ)
Saints Joachim and Anne Nursing and Rehabilitation Center
Sephardic Nursing and Rehabilitation Center
St. Barnabas Rehabilitation and Continuing Care Center

Certified Home Health Agencies/Hospice Agencies
The Brooklyn Hospital Center Certified Home Care Agency (NewYork-Presbyterian)
Dominican Sisters Family Health Service
Extended Home Care
First to Care
Health & Home Care (New York City Health and Hospitals Corporation)
North Shore-LIJ Home Care Network
North Shore-LIJ Hospice Network
Visiting Nurse Service of New York
Visiting Nurse Service of New York Hospice

Read about the participants and their projects from Round 1 and Round 2.

The Transitions in Care–Quality Improvement Collaborative, or TC-QuIC, which ran from March 2010 to June 2012, addressed one of health care’s most persistent challenges—transitions of chronically or seriously ill patients between health care settings, e.g., from hospital to rehab facility or home. (Read the full report summarizing the collaborative's work.) The goal of the multi-provider initiative was to improve both patient care and patient, family, and staff satisfaction. TC-QuIC is an integral component of the Fund’s Next Step in Care campaign, which also includes a website with guides and materials for family caregivers and health care providers and outreach to community groups that serve family caregivers.

Fostering changes in individual and organizational practice and culture, TC-QuIC worked to create better coordination and communication between health care organizations that share patients, and better integration of family caregivers in planning and implementing transition care plans. By building effective partnerships that recognize and support family caregivers and by developing better tools for critical tasks such as medication management, the initiative helped providers explore ways to avoid problems that undermine patient care and too often lead to preventable hospital readmissions.

From throughout the New York metropolitan area, hospitals, skilled nursing facilities, certified home health agencies, and hospices (see box at right) participated in TC-QuIC. With assistance from Fund staff and expert faculty members and often through cross-organizational partnerships, participants focused on:

  • Identifying hands-on family caregivers for effective communication and integration into the care planning process;
  • Assessing the needs of those family caregivers, such as for education and training, or services to supplement care;
  • Including family caregivers in medication reconciliation, which can provide health care professionals with additional information critical to proper care of the patient;
  • Meaningfully engaging family caregivers in planning for discharge;
  • Effectively preparing family caregivers for the actual day of discharge;
  • Sharing the right information with the next setting of care, so that care of the patient can be as seamless as possible, without the family caregiver being put in the position of “making it work”; and
  • Advance care planning with family caregivers, to increase the patient’s and the family’s understandings of the patient’s prognosis, as well as improve self-determination about how care should be handled – in some cases, reducing readmissions or increasing use of hospice.

At each stage, participating organizations identified specific challenges, developed and evaluated new processes to tackle those challenges, and worked toward implementing successful processes across large sections of each organization. Many of the teams used guides and materials available on the Next Step in Care website.

Data on the collaborative's findings are being analyzed and will be summarized and made available in the coming months.

See descriptions of the initiatives addressed in TC-QuIC in Round 1 and Round 2.

 

 
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Resources for family caregivers and health care providers are available at our Next Step in Care website.

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