, Director, Integrated Care Management

This session will examine one organization’s investment in reducing readmissions, which includes a specific focus on continuing practices and implementing additional improvements in four major areas: (1.) patient-centered, “teach back” education prior to discharge, (2.) emphasis on communication with – and transition to – primary care physician (PCP) or accepting physician, (3.) creation of a post-discharge “safety net” (telephone calls, discharge clinic and other services), and (4.) other diagnosis-specific interventions, such as increased collaboration and partnership with community clinics, home health agencies and other providers.

Learning Objectives:
1. Describe how to start a transition of care program and what model(s) to follow or emulate

2. Discuss who to select as members of the team

3. Understand patient population selection

4. Understand post-acute care provider relationships - how to select, foster and grow together