Improve quality and safety in all long-term care settings and during transitions across settings.

Outcome

• Disseminate findings from AHRQ nursing home fall prevention program.
• Distribute report on implementation of evidence-based protocols for pressure ulcers prevention in nursing homes.
• Synthesize recent research findings on what aspects of nursing home care prevents inappropriate hospitalizations.

SG-1/3/5
HP-1

Improve community-based care to maximize function and community participation, and prevent inappropriate institutionalization and hospitalizations.

Outcome

• Synthesize recent research findings on what aspects of community-based services and care in assisted living can prevent inappropriate institutionalization and hospitalizations.
• New Freedom Initiative: Initiate evaluation plan to assess findings from youth in transition (from pediatric to adult services) projects.

SG-1/3/5
HP-1

Improve coordination of formal long-term care with hospital care, primary care, and informal caregivers to facilitate clinical decisionmaking and assure timely transfer of clinical data.

Outcome

• Initiate dissemination of E-communication tool (i.e., a Web-based tool to improve coordination between hospital, primary care and home care clinicians and patients and their informal care providers to improve care planning and self-care).
• Disseminate E-communication user aids and expand network of provider partnerships to jumpstart use of E-communication tools by multiple provider organizations.
• Complete initial identification of user needs and barriers associated with 1st generation E-communication tool use.
• Draft contractual award materials for 2007 multiple provider implementation of 2nd generation E-communication tool in diverse geographic settings.

SG-1/3/5
HP-1

Improve information about services and quality so that consumers can make informed choices about the care they receive.

Outcome

• Determine final sampling methodology and plan of implementation to enhance measurement on the long-term care population.
• Publish report on how States monitor assisted living/residential care facilities and how States report to consumers.
• Produce report on the state-of-the-art of instruments and tools available to profile assisted living/residential care.

SG-1/3/5
HP-1

* SG = Strategic Goal; HP = Healthy People