title: Improving transitions cuts HF readmissions.
abstract: Cooley Dickinson Hospital in Northampton, MA, has cut heart failure readmissions by 50% by collaborating with post-acute providers and improving patient education. Coalition focuses on improved communication as patients transition. Transition coaches work with at-risk patients. Patients use a personal health record to track their progress.
mesh_terms: D003266:Continuity of Patient Care / Q000458:organization & administration* / Q000592:standards; D055991:Health Records, Personal; D006333:Heart Failure / Q000628:therapy*; D018575:Home Care Services, Hospital-Based / Q000458:organization & administration* / Q000592:standards; D006801:Humans; D010359:Patient Readmission / Q000592:standards* / Q000639:trends