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UCares care coordinators are the hub for communication among providers treating the Minneapolis health plans dual eligible members enrolled in one of two care plans depending on their age.
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Carondelet Health Network and the Pima Council on Aging have partnered to provide follow-up care coordination for at-risk patients who are being discharged from the hospital.
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Patients discharged from an acute care hospital to an acute rehabilitation facility are more likely to be readmitted to the hospital within 30 days if they score poorly on the Functional Independence Measure (FIM) test, which measures a persons ability to perform activities of daily living, according to a study at Johns Hopkins Medicine.
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Transitions from the hospital go smoother and patients are less likely to be readmitted when the providers at the next level of care get detailed and complete information about the patient, says Sandy Merlino, RN, MBA, vice president, integrated delivery systems and hospital market development for Visiting Nurse Service of New York.
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A team effort at Holzer Health System helped reduce the rate of all-cause readmissions by 20%.
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1. Look beyond the data.
2. Consult the palliative care team.
3. Reach out to embedded case managers.
4. Facilitate early discharges.
5. Follow up with assisted living residents.
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More hospitals than ever before are being penalized by the Centers for Medicare & Medicaid Services for excess readmissions and insurers are starting to develop their own readmission reduction programs.
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Joint replacement surgery may seem routine, but patients are being readmitted to the hospital for a variety of reasons, including comorbidities, poor outcomes from therapy, and deep venous thrombosis.
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A lot of people think they want to work for themselves, but they find out its not glamorous, and it does take a lot of hard work.
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There's a lot more to being an independent case manager than just announcing that you're open for business. Being successful takes a lot of planning.