1. Innovative Information Technology–Powered Population Health Care Management Improves Outcomes and Reduces Hospital Readmissions and Emergency Department Visits 
Sharon Anderson, BSN, MS, RN, CPHQ, Michele Campbell, MSM, RN, CPHQ, Donna Mahoney, MHCDS, Ann Kathryn Muther, MSN, RN, Janice Nevin, MD, MPH, Patricia Resnik, MBA, MJ, RRT-NPS, CPHQ, Tabassum Salam, MD, CHCQM, Terri Steinberg, MD, MBA 
Joint Commission Journal on Quality and Patient Safety 
Volume 43, Issue 7, Pages (July 2017)
DOI: /j.jcjq
Copyright © 2017 The Joint Commission Terms and Conditions

2. Figure 1
The number of patients discharged to home with self-care or with home health care increased by 30%—from 61% (2,151 of 3,510 discharges) before the start of Care Link in January 2015 to 80% (1,283 of 1,611 discharges) in February UCL, upper control limit; LCL, lower control limit.
Joint Commission Journal on Quality and Patient Safety  , DOI: ( /j.jcjq )
Copyright © 2017 The Joint Commission Terms and Conditions

3. Figure 2
Through the Care Link team's support, the percentage of patients with total joint (hip or knee) replacement who had one or more unplanned rehospitalizations within 90 days of discharge decreased from 8% (294 of 3,501 discharges) in January 2015, prior to the start of the Care Link program, to 6% (162 of 2,760 discharges) in December UCL, upper control limit; LCL, lower control limit.
Joint Commission Journal on Quality and Patient Safety  , DOI: ( /j.jcjq )
Copyright © 2017 The Joint Commission Terms and Conditions

4. Figure 3
For the period between the inception of Care Link support in October 2015 and February 2017, the number of patients being discharged to home with self-care or with home health care increased by12%—from 64% (1,544 of 2,404 discharges) to 72% (1,032 of 1,437 discharges). UCL, upper control limit; LCL, lower control limit.
Joint Commission Journal on Quality and Patient Safety  , DOI: ( /j.jcjq )
Copyright © 2017 The Joint Commission Terms and Conditions

5. Figure 4
There was a consistent downward trend in 90-day readmissions of patients with congestive heart failure—from 40% (964 of 2,428 discharges) in October 2015, at the start of the Care Link program, to 34% (420 of 1,228 discharges) in December UCL, upper control limit; LCL, lower control limit.
Joint Commission Journal on Quality and Patient Safety  , DOI: ( /j.jcjq )
Copyright © 2017 The Joint Commission Terms and Conditions

6. Figure 5
The Care Link interventions, which were all implemented by July 2016, resulted in an 8% reduction in the 30-day readmission rate—from 11% (30 of 280 patients transferred to SNFs) for July 2015–December 2015 to 10% (37 of 374 patients) for July 2016–December The total number of unplanned hospital admissions, including inpatient, emergency department (ED) encounters, and observation (Obs) visits, decreased from 20% (56 of 280 patients transferred to SNFs) to 17% (62 of 374 patients).
Joint Commission Journal on Quality and Patient Safety  , DOI: ( /j.jcjq )
Copyright © 2017 The Joint Commission Terms and Conditions

7. From left to right: Donna Mahoney, Michele Campbell, Sharon Anderson, Tabassum Salam, Patty Resnik, Terri Steinberg.
Joint Commission Journal on Quality and Patient Safety  , DOI: ( /j.jcjq )
Copyright © 2017 The Joint Commission Terms and Conditions