-- The Southcentral Foundation's values program in Alaska, which involves a unique primary care team and extended family in the care of Native Alaskans. By embracing the culture and values of the community into its care model, the program involves patients and families in care and as a result has kept people healthier and out of the hospital.
-- University of Pennsylvania's transitional care model, which has nurses monitor patients beyond discharge to ensure that they get the appropriate care they need in the community and don't end up back in the hospital. This has been replicated in several sites, including Kaiser Permanente in California.
Although each of the 24 delivery models is distinct in its own way, many share the following common elements:
-- Elevate the role of nurses by shifting them from a traditional caregiver role to one that integrates and coordinates care for patients; nearly all of the projects do this.
-- Deploy an interdisciplinary team for care that includes nurses, physicians, physical therapists, social workers, and pharmacists.
-- Bridge the continuum of care by extending their focus beyond the sponsoring organizations primary setting; nearly half of the models provide care that follows the patient outside of the hospital in the home, outpatient clinics, or long-term care setting.
-- Promote home as the setting of care. Six of the projects profiled extend the typical definition of health care, relying on patient home as the primary location.
-- Target high-users of health care, focusing on older adults who are heavy users of health care.
-- Sharpen the focus on patients by actively involve patients and their families in care planning and delivery.
-- Incorporate new techno
|SOURCE Health Workforce Solutions LLC|
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