title: Hospital, nurses team up to prevent readmissions.
abstract: University Hospital in Newark, NJ, and the Visiting Nurses Association Health Group are working together to provide intensive case management to Medicare and Medicaid beneficiaries and uninsured patients with multiple chronic conditions. Hospital case managers identify patient eligible for the program. Patient navigators employed by the VNA and funded by the hospital provide education while patients are in the hospital. Navigators visit the patients every day in the hospital and link them with primary care providers for follow up.
mesh_terms: D003266:Continuity of Patient Care / Q000458:organization & administration; D003299:Cooperative Behavior; D006779:Hospitals, Public; D006801:Humans; D009515:New Jersey; D009741:Nursing Staff, Hospital; D019982:Organizational Case Studies; D010359:Patient Readmission