title: Nine hospitals collaborate to prevent readmissions.
abstract: The Rio Grande Valley Readmission Coalition, which includes nine hospitals and the Agency on Aging is collaborating to prevent readmissions for at-risk patients. Program is funded through the Community-Based Care Transition Project administered by the Centers for Medicare & Medicaid Services. Hospital case managers refer appropriate patients to the program and check for eligibility using a Web-based data exchange program that includes criteria for eligibility. Agency on Aging health coaches visit patients in the hospital and follow up for 30 days after discharge.
mesh_terms: D019090:Case Management / Q000458:organization & administration; D006761:Hospitals; D006801:Humans; D007373:Interinstitutional Relations; D019982:Organizational Case Studies; D010359:Patient Readmission; D058996:Quality Improvement / Q000458:organization & administration; D013781:Texas