Summary: Broome County, New York's Community Alternative Systems Agency -- also known as CASA -- has a bird's eye view of every type of care setting, explains its director, Michelle Berry. The program's in-home longterm care assessment looks beyond the individual's physical condition, she says, taking note of social, emotional and environmental factors. To help patients own their care plans and improve recordkeeping, CASA hopes to soon train the homebound to use a "guest book" that will require visiting caregivers -- nurse, physician, physicial therapist, etc. -- to "sign in" and record the reason for each visit. This hard copy record would be the prototype for an eventual online care record, Berry explains. Berry, along with Nora Baratto, manager of the case management department at St. Peter's Hospital's CHOICES program in Albany, New York, described the strategies their organizations have used to improve the hospital discharge process during an October 23, 2007 webinar, Best Practices in Hospital Discharge to Reduce Preventable Readmissions.
