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To prevent readmissions when patients are transitioning from the acute care hospital to an inpatient rehabilitation center, case managers should make sure the patients are appropriate for acute rehab, that their medical conditions are stable, and that they can tolerate three hours of therapy every day.
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Kaiser Permanente's six-step process to improve transitions of care has resulted in reduced preventive hospital readmissions, an increase in the percentage of patients with physician appointments within five days of discharge, and raised patient satisfaction scores.
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Providers and payers alike are recognizing that ensuring smooth transitions when patients move between levels of care and implementing projects to help transitioning patients avoid an emergency room visit or a hospital readmission is the right thing to do.
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Aetna's pilot program sending advanced practice nurses into the home of at-risk Medicare patients within seven days of hospital discharge resulted in a 20% decrease in hospital readmissions, over and above the 23% readmission reductions already achieved by the health plan's case management program for Medicare Advantage patients.
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On any given day, the ED at Mercy Hospital in Springfield, MO, has two zone captains acting as mini-charge nurses, for the east and west sides of the department.
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After interviewing hundreds of patients and family members, a multi-disciplinary team at Kaiser Permanente redesigned the process for transitioning patients from the hospital to home and developed a list of six processes that should happen during every discharge for every patient.
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Healthcare organizations in a variety of settings are leveraging today's technology to increase the efficiency of case managers and nurses and for early intervention of patients who are experiencing exacerbation of their disease or other problems that might lead to an emergency department visit or hospitalization.
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If you say it out loud, people will agree intuitively: You can learn more from your failures than from your successes. But that agreement doesn't mean people want to trumpet what doesn't work.
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MetroHealth System's care coordination program for the uninsured, Partners in Care, has resulted in 34.8% fewer inpatient stays at an average cost of 15.4% less than a demographically similar group of patients who were not enrolled in the program.