title: Improved coordination of care for elderly patients.
abstract: One of the early steps in the development and implementation of a care coordination program designed to improve the hospital's response to the elderly population of a small, rural hospital was the identification of those elders at "high risk" of institutionalization or who used costly services. This process involved data collection over a 2-year period from multiple entry points into the hospital care delivery system. The subsequent emergency database is used to disseminate patient-centered information to staff, rather than episode-centered. The hospital's efforts are described, giving both methods and results.
authors.affiliation: Margaret R. Pardee Memorial Hospital, Hendersonville, N.C., USA.
authors.forename: B J
authors.initials: BJ
authors.lastname: Hammer
mesh_terms: D000368:Aged; D003266:Continuity of Patient Care; D015577:Geriatric Assessment; D006301:Health Services Needs and Demand; D006780:Hospitals, Rural; D006801:Humans; D010359:Patient Readmission