Knowledge and Empowerment Across the Continuum For Effective Disease Management and Reduction of Readmissions

A gap analysis was conducted. Key themes emerged in this analysis such as inadequate preparation for self-management of medical conditions and gaps/concerns acorss the continuum including: communication, medication reconciliation, and variations in knowledge sets of caregivers. Through continued research, observations and work sessions, the following strategies for change were identified and implemented: development of a care path to guide members of the hospital team in preparing the patient and family for discharge; resource materials; weight logs; diet information; appointment calendar; red/yellow/green zone magnets for home display and a reference for family members, primary care physicians and office staff, nursing homes, assisted living centers, and home health agencies.

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This case study is part of the Illinois Hospital Association's annual quality awards. Each year, IHA recognizes and celebrates the achievements of Illinois hospitals in continually improving and transforming health care in the state. These hospitals are improving health by striving to achieve the Triple Aim--improving the patient experience of care (including quality and satisfaction); improving the health of populations; and reducing the per capita cost of health care.

Award recipients achieve measurable and meaningful progress in providing care that is:

• Safe
• Timely
• Effective
• Efficient
• Equitable
• Patient-centered

(The Institute of Medicine's six aims for improvement.)