title: Hospitals, providers collaborate on transitions.
abstract: Baystate Health, a three-hospital system with headquarters in Springfield, MA, is partnering with post-acute providers to improve transitions as patients move through the continuum of care. A multidisciplinary post-acute performance team partnered with post-acute providers to determine why patients are readmitted to the hospital and to work on ways to avoid readmissions. Facilities share information with the hospitals how they operate and what they need to ensure patients receive the care they need. The health system's director of post-acute services holds regular meetings with providers to brainstorm on improving patient care.
mesh_terms: D003266:Continuity of Patient Care / Q000458:organization & administration* / Q000592:standards; D018450:Disease Progression; D015285:Hospital-Patient Relations; D006801:Humans; D007373:Interinstitutional Relations; D010351:Patient Discharge / Q000592:standards*; D010359:Patient Readmission / Q000592:standards* / Q000639:trends; D010817:Physician-Patient Relations; D011368:Professional-Family Relations; D012866:Skilled Nursing Facilities / Q000458:organization & administration* / Q000592:standards; D017216:Telemedicine / Q000639:trends