Hospital Best Practices and Recommended Strategies
Prepare for an integrated care delivery system of the future by using Rural Health Value tools on:
Initiate community health coordination planning:
- Develop transition of care committee to include hospitals, physicians, emergency medical service (EMS), other local agencies such as Home Health and Area Agency on Aging, as well as non-traditional health champions such as schools and churches
- Build awareness of local health care services to improve transition of care and community care coordination
- Discuss and strategize how to meet community needs and determine the type of support needed
- Use IHI’s Stoplight Tools to assist patients with monitoring and managing their chronic condition
- Use the Network Care Coordination Workshop tools and trainings to initiate the development of a network care coordination service. Refer to the Krieder Care Coordination Worksheet for planning development process.
- Consider using health navigators (non-medical health workers) to help improve patient outcomes by helping them learn about their disease and get screening and treatments
- Refer to Kentucky Homeplace on how to use Community Health Workers to assist patients and families identify and find solutions to their health care needs
- Use Care Coordinator/Manager Model as liaison with the community to help individuals with complex health conditions to navigate the health care system
- Use the Minnesota e-Health Roadmap cases, a person-centered view, recommendations and actions to support and accelerate the adoption of e-health for behavioral health, local public health, Long-Term and post-acute care and social services.
- Use the Flex Monitoring Team’s State-level Quality, Financial and Community Engagement Data to support planning