Jove
Visualize
Contact Us
JoVE
x logofacebook logolinkedin logoyoutube logo
ABOUT JoVE
OverviewLeadershipBlogJoVE Help Center
AUTHORS
Publishing ProcessEditorial BoardScope & PoliciesPeer ReviewFAQSubmit
LIBRARIANS
TestimonialsSubscriptionsAccessResourcesLibrary Advisory BoardFAQ
RESEARCH
JoVE JournalMethods CollectionsJoVE Encyclopedia of ExperimentsArchive
EDUCATION
JoVE CoreJoVE BusinessJoVE Science EducationJoVE Lab ManualFaculty Resource CenterFaculty Site
Terms & Conditions of Use
Privacy Policy
Policies

Related Concept Videos

Discharge Summary Forms01:31

Discharge Summary Forms

1.3K
The discharge summary is crucial as it enables a smooth transition from a healthcare facility to a patient's home or another care setting. This critical document facilitates seamless continuity of care, ensuring patients receive the necessary support and attention.
Here's a detailed look at the key components and guidelines for preparing a discharge summary:
1.3K
Nursing Interventions I: Taxonomy of Nursing Interventions01:03

Nursing Interventions I: Taxonomy of Nursing Interventions

3.9K
Nursing interventions are chosen as part of the planning process to achieve patient outcomes. Once nursing diagnoses are determined, the goals and outcomes are specified, then the nursing interventions are selected and individualized according to the patient's situation.
A nursing intervention is a treatment or action based on scientific concepts and knowledge from the nursing, behavioral, and physical sciences. Identifying and prioritizing nursing interventions based on the desired outcome...
3.9K
RC Circuits: Discharging A Capacitor01:27

RC Circuits: Discharging A Capacitor

4.5K
One of the applications of an RC circuit is the relaxation oscillator. The relaxation oscillator comprises a voltage source, a capacitor, a resistor, and a neon lamp. The lamp acts like an open circuit (infinite resistance) until the potential difference across the neon lamp reaches a specific voltage. At that voltage, the lamp acts like a short circuit (zero resistance), and the capacitor discharges through the neon lamp and produces light. Once the capacitor is fully discharged through the...
4.5K
Nursing Interventions II: Selecting and Classifying the Nursing Interventions01:29

Nursing Interventions II: Selecting and Classifying the Nursing Interventions

3.4K
Creating and executing a nursing diagnosis helps nurses plan care and guide patient, family, and community interventions. They are developed based on a patient's physical evaluation and support measuring the outcomes. It is not recommended to select random interventions throughout the planning process. Instead, consider the following six essential factors when choosing interventions:
3.4K
Nursing Implementation01:15

Nursing Implementation

6.2K
Implementation is the execution of the nursing care plan developed during the planning phase.
The five steps to implementing effective nursing care include reassessing the patient, reviewing and revising the existing nursing care plan, organizing the resources and care delivery, anticipating and preventing complications, and implementing nursing interventions.
6.2K
Conservation of Small Populations02:04

Conservation of Small Populations

17.4K
Small population sizes put a species at extreme risk of extinction due to a lack of variation, and a consequent decrease in adaptability. This weakens the chances of survival under pressures such as climate change, competition from other species, or new diseases. Large populations are more likely to survive pressures such as these, as such populations are more likely to harbor individuals that have genetic variants that are adaptive under new stresses. Small populations are much less...
17.4K

You might also read

Related Articles

Articles linked to this work by shared authors, journal, and citation graph.

Sort by
Same authorSame journal

Optimizing Outcomes in the ACCESS Model: Why Provider Integration is Critical to Long-Term Success.

Population health management·2026
Same author

A low-cost calcium silicate hydrate with an exceptionally large sequestration capacity for aqueous divalent nickel.

Scientific reports·2026
Same author

Shape and size of foveal avascular zone in normal subjects using optical coherence tomography angiography (OCTA) : A retrospective analysis.

JPMA. The Journal of the Pakistan Medical Association·2026
Same author

Advance care planning in the Asia Pacific region: comparative implementation study.

BMJ supportive & palliative care·2026
Same author

Understanding of Key Facts Relevant to Dialysis Care Among Patients Undergoing Hemodialysis.

The Permanente journal·2026
Same author

The health informatics centre: a safe haven and trusted research environment enabling world-leading research.

International journal of population data science·2026

Related Experiment Video

Updated: Feb 7, 2026

The Participant-Reported Implementation Update and Score PRIUS: A Novel Method for Capturing Implementation-Related Data Over Time
06:05

The Participant-Reported Implementation Update and Score PRIUS: A Novel Method for Capturing Implementation-Related Data Over Time

Published on: February 19, 2021

1.8K

Implementation and Outcomes from a Post-Discharge Intervention Program in a Medicare ACO Population.

Katherine H Schiavoni1,2,3,4, Yuchiao Chang2,4, Christopher Hall1

  • 1Mass General Brigham Population Health Services Organization, Somerville, Massachusetts, USA.

Population Health Management
|February 6, 2026
PubMed
Summary
This summary is machine-generated.

A new standardized post-discharge program reduced 30-day readmissions for Medicare patients in an Accountable Care Organization (ACO). This system-wide intervention improved follow-up appointment rates, demonstrating value in value-based care models.

Keywords:
Medicare shared savings programaccountable care organizationpost-discharge programpreventable readmissionstransitional care management

More Related Videos

Author Spotlight: Implementation of BIVA for Analyzing Disease Risk Factors in Patients with Low Body Cell Mass
07:44

Author Spotlight: Implementation of BIVA for Analyzing Disease Risk Factors in Patients with Low Body Cell Mass

Published on: July 14, 2023

1.7K
Mindfulness in Motion MIM: An Onsite Mindfulness Based Intervention MBI for Chronically High Stress Work Environments to Increase Resiliency and Work Engagement
12:22

Mindfulness in Motion MIM: An Onsite Mindfulness Based Intervention MBI for Chronically High Stress Work Environments to Increase Resiliency and Work Engagement

Published on: July 1, 2015

24.6K

Related Experiment Videos

Last Updated: Feb 7, 2026

The Participant-Reported Implementation Update and Score PRIUS: A Novel Method for Capturing Implementation-Related Data Over Time
06:05

The Participant-Reported Implementation Update and Score PRIUS: A Novel Method for Capturing Implementation-Related Data Over Time

Published on: February 19, 2021

1.8K
Author Spotlight: Implementation of BIVA for Analyzing Disease Risk Factors in Patients with Low Body Cell Mass
07:44

Author Spotlight: Implementation of BIVA for Analyzing Disease Risk Factors in Patients with Low Body Cell Mass

Published on: July 14, 2023

1.7K
Mindfulness in Motion MIM: An Onsite Mindfulness Based Intervention MBI for Chronically High Stress Work Environments to Increase Resiliency and Work Engagement
12:22

Mindfulness in Motion MIM: An Onsite Mindfulness Based Intervention MBI for Chronically High Stress Work Environments to Increase Resiliency and Work Engagement

Published on: July 1, 2015

24.6K

Area of Science:

  • Health Services Research
  • Quality Improvement in Healthcare
  • Value-Based Care Models

Background:

  • Preventable hospital readmissions significantly increase healthcare costs, with about 26% of Medicare medicine readmissions deemed preventable.
  • Implementing effective post-discharge interventions at scale across diverse health systems presents challenges, and evidence remains mixed.
  • Accountable Care Organizations (ACOs) aim to improve care quality and reduce costs, making readmission reduction a key objective.

Purpose of the Study:

  • To evaluate a novel, multidisciplinary, system-wide post-discharge intervention designed to reduce 30-day readmissions within a Medicare Shared Savings Program (MSSP) ACO.
  • To test the hypothesis that standardizing intervention delivery through a high-fidelity workflow would decrease readmission rates.
  • To assess the impact of the intervention on 30-day readmission rates and emergency department (ED) presentations.

Main Methods:

  • A prospective cohort study compared outcomes between patients at pilot intervention sites and a propensity-matched control group.
  • The intervention involved a standardized, multidisciplinary workflow: chart review, medication reconciliation by a pharmacist, and post-discharge assessment by a registered nurse.
  • Data collection focused on 30-day readmission rates, 30-day ED presentations, and 14-day follow-up appointment rates.

Main Results:

  • The intervention cohort demonstrated a directional reduction in 30-day readmission rates (13.5% vs. 16.3%, P = 0.07) compared to matched controls.
  • No significant difference was observed in 30-day emergency department presentations between the intervention and control groups.
  • The intervention group showed a significantly higher rate of 14-day follow-up appointments (70.0% vs. 65.3%, P = 0.025).

Conclusions:

  • A centralized, standardized post-discharge intervention strategy can effectively reduce readmissions within an ACO setting.
  • Structured, system-level interventions are crucial for improving care transitions and patient outcomes in value-based care models.
  • This approach highlights the potential for scalable, evidence-based interventions to enhance healthcare quality and efficiency.