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Post-discharge interventions reduce readmissions by 20%.
Hosp Case Manag. 2015 May;23(5):58-9
Authors:
Abstract
Phone calls from nurses at Ochsner Health System's Care Coordination Center within 24 to 48 hours after discharge have reduced readmissionsfor at-risk patients who receive calls by 20%. The program was developed as part of Ochsner's accountable care organization and is expanding across the nine-hospital health system. Nurse case managers reinforce discharge education, complete medication reconciliation, and arrange follow-up visits with primary care physicians and specialists. When patients have long-term needs, they are referred to Ochsner's outpatient complex case management program.
PMID: 25916002 [PubMed - indexed for MEDLINE]