Providers team up to cut HF readmissions.
A clinical integration case manager acts as heart failure liaison at Hartford Physician Hospital Organization in Hartford, CT. She coordinates care between the hospital, Hartford Physicians Association, home health agencies, and skilled nursing facilities. The initiative has kept the readmission rate at 11% to 13%. The liaison attends heart failure physician rounds and receives most referrals during the rounds. She meets the patients in the hospital, then contacts them by phone as often as necessary for 30 days or more after discharge. She collaborates with staff at the home health agencies and skilled nursing facilities to ensure that patients are receiving the care and education they need.
D019090:Case Management; D003237:Connecticut; D006333:Heart Failure; D006786:Hospitals, Urban; D006801:Humans; D019982:Organizational Case Studies; D010359:Patient Readmission