Introduction: The evaluation research was conducted to establish the role of primary health care in the process of rehabilitation, activation and employment of the long-term unemployed citizens. Empirical data was gathered from 17 municipal projects. Projects aimed to develop health care services for the unemployed and to improve co-operation between health care services and local activation an...

BACKGROUND Interprofessional education (IPE) is crucial in fostering effective collaboration and optimal team-based patient care, all of which improve patient care and outcomes. Appropriate interprofessional communication is especially important in geriatrics where patients are vulnerable to adverse effects across the care continuum. Transitions in geriatric care are complex, involving several ...

OBJECTIVES This study examined whether the extra-individual factors of better access to care and supplementary health insurance coverage can prevent, delay, or reverse transitions from functional independence to disability over time. METHODS Six years of the Medicare Current Beneficiary Survey were pooled, yielding 40,793 transition periods for community residents aged 66 or older. Multinomia...

OBJECTIVES To examine how skilled nursing facility (SNF) nurses transition the care of individuals admitted from hospitals, the barriers they experience, and the outcomes associated with variation in the quality of transitions. DESIGN Qualitative study using grounded dimensional analysis, focus groups, and in-depth interviews. SETTING Five Wisconsin SNFs. PARTICIPANTS Twenty-seven registe...

The Centers for Medicare and Medicaid Services (CMS) has launched the Partnership for Patients initiative, promising a 20% reduction in readmissions nationally across all payers by December 31, 2013. To address this ambitious goal, CMS has awarded grants to Hospital Engagement Networks, Pioneer Accountable Care Organizations, and the Community-based Care Transitions Program, as well as institut...

INTRODUCTION Following hip fracture surgery, patients often experience multiple transitions through different care settings, with resultant challenges to the quality and continuity of patient care. Family caregivers can play a key role in these transitions, but are often poorly engaged in the process. We aimed to: (1) examine the characteristics of the family caregivers' experience of communica...

Americans over age 65 constitute a larger percentage of the population each year: from 14% in 2010 (40 million elderly) to possibly 20% in 2030 (70 million elderly). In 2015, an estimated 66 million people provided care to the ill, disabled, and elderly in the United States. In 2000, according to the Centers for Disease Control and Prevention (CDC), 15 million Americans used some form of long-t...

BACKGROUND Safe patient transitions depend on effective communication and a functioning care coordination process. Evidence suggests that primary care physicians are not satisfied with communication at transition points between inpatient and ambulatory care, and that communication often is not provided in a timely manner, omits essential information, or contains ambiguities that put patients at...

Chronic health conditions are overrepresented among prisoners who often face barriers to medical care following release. Transitions clinics seek to provide timely access to medical care following release. This retrospective cohort study investigated care delivery and health outcomes for recently released prisoners receiving care at the Bronx Transitions Clinic. Among 135 recently released pris...

Preventable hospital admissions and readmissions are indicators of health system fragmentation associated with suboptimal patient outcomes and avoidable costs of care. Three case studies illustrate the potential of care management programs to address this problem by improving care coordination and transitions among high-risk patients. Study sites included two academic medical centers and a mana...