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Care coordination cuts admissions, ED visits, LOS.
Hosp Case Manag. 2013 May;21(5):67-8
Authors:
Abstract
Gundersen Health in La Crosse, WI, has decreased the length of stay by 46% and unplanned admissions or emergency department visits by 64% through an integrated care coordination program that focuses on the most complex patients. Care coordinators who are nurses or social workers follow at-risk patients through the continuum, interacting with them face-to-face in the clinic or hospital and following up by telephone. Patients are identified for the program using a two-pronged tool that assesses both healthcare and psycho-social needs. Care coordinators follow the patients for as long as a year.
PMID: 23667949 [PubMed - indexed for MEDLINE]