All Content

Studies show that home visits to patients recently discharged from the hospital can help prevent unnecessary readmission.¹ Providing continuing care instructions to patients in their homes—where they may be less overwhelmed than in the hospital—may also be a key mechanism for preventing readmission.² Home visit clinicians and technicians can note any health concerns in the home environment and help patients understand their care plan in the context of that environment.²

The MOQI seeks to reduce avoidable hospitalization among nursing home residents by placing an advanced practice registered nurse (APRN) within the care team with the goal of early identification of resident decline. In addition to the APRN, the MOQI involves nursing home teams focused on use of tools to better detect acute changes in resident status, smoother transitions between hospitals and nursing homes, end-of-life care, and use of health information technology to facilitate communication with peers. As a result of the innovation, resident hospitalizations declined.