TC-QuIC Partnerships and Projects
Round 1, 2010-2011
The health care providers participating in the Transitions in Care–Quality Improvement Collaborative addressed specific challenges in transitions through eleven diverse partnerships and projects:
Partners: Beth Israel Medical Center (Continuum Health Partners), Visiting Nurse Service of New York
Focus of project: Targeting family caregivers of Chinese patients with a diagnosis of congestive heart failure, who are moving between the hospital setting and home, this project is primarily using Chinese-language versions of Next Step in Care materials for its quality improvement efforts.
Partners: Coney Island Hospital (New York City Health and Hospitals Corporation), Saints Joachim and Anne Center for Rehabilitation
Focus of project: These two providers, near each other in Brooklyn’s Coney Island neighborhood, are examining admissions and readmission from the nursing home to the hospital resulting from medication reconciliation problems. Together, they are targeting family caregivers of patients using anticoagulant and insulin therapies that may contribute to transition problems or poor outcomes, and are working to improve communication between settings and integrate family caregivers into the care plan.
Partners: Franklin Hospital (North Shore-LIJ), North Shore-LIJ Home Care, Orzac Center for Rehabilitation (North Shore-LIJ), North Shore-LIJ Hospice Network
Focus of project: Medication reconciliation and ongoing management are critical for heart failure patients, and play a prominent role in this improvement effort. This partnership is working to improve transitions for heart failure patients through more effective communication between acute and home care settings, between hospital and rehabilitation settings, and between home- and hospital-based hospice.
Partners: Maimonides Medical Center, Lutheran Hospital (Medical/Surgery Unit and Acute Inpatient Rehabilitation Unit), First to Care Home Care, Lutheran Augustana Center for Skilled Nursing, Visiting Nurse Service of New York
Focus of project: The acute care settings in this large partnership are using the identification and assessment of caregivers as an opportunity to educate family caregivers on the differences between acute and transitional care settings, with a goal of improving transitions between them. The team is also working to improve the preparation and education of family caregivers as they move from one organization to another.
Partners: Metropolitan Hospital Center (New York City Health and Hospitals Corporation), HHC Health and Home Care
Focus of project: This partnership between two members of New York’s public health care system has set goals of improving family caregiver awareness, education, and preparation for ongoing medication management in the home.
Partners: Montefiore Medical Center, Jewish Home Lifecare’s Weinberg Family Campus in the Bronx
Focus of project: This Bronx-based partnership is focused onincreasing medication adherence, improving caregiver satisfaction, and reducing readmissions.
Partners: New York Hospital Medical Center Queens, Visiting Nurse Service of New York
Focus of project: Working to improve transitions between hospital and home care settings, these providers are concentrating on their sickest patients who are supported by family caregivers.
Partners: NYU-Langone Medical Center, Visiting Nurse Service of New York
Focus of project: NYU and VNSNY are developing shared protocols for transferring information about the family caregiver between providers at the time of transition.
Partners: Allen Hospital (NewYork-Presbyterian), Isabella Geriatric Center
Focus of project: This partnership of acute and short-term rehabilitation providers emphasizes increased communication with and preparation of the family caregiver.
Partners: Cobble Hill Health Center, Extended Home Care
Focus of project: These providers are striving to integrate more effective assessment of and collaboration with family caregivers to improve transitions between subacute rehabilitative services and home care.
Partners: Jewish Home Lifecare’s Manhattan Division
Focus of project: Jewish Home Lifecare has created a unique partnership: its own subacute rehabilitation and long-term care settings. It is working to improve transitions between the two.
