This session will examine the implementation of a transitions of care program designed to improve patient care and reduce readmissions. The Transitions Team consists of two nurse case managers, a pharmacist and a physician, and utilizes a unique, risk stratifying algorithm which places patients in high, moderate or low risk categories for readmission. Speakers will discuss the algorithm; the assessment process; the procedure employed for follow-up, post-discharge phone calls; barriers and challenges encountered; and considerations in creating coalitions and utilizing community resources. Outcomes data will also be shared.

Learning Objectives:
1. Describe the algorithm used to risk stratify patients and identify those at high risk for readmission

2. List three most common medication discrepancies occurring during transitions from the hospital to home or other settings

3. Explain two successful methods for identifying barriers and increasing adherence during transitions