title: Community collaboration helps cut readmits.
abstract: Charles Cole Memorial Hospital in Coudersport, PA, slashed its readmission rate by 15.9% by collaborating with post-acute providers and making internal improvements. Community transition team members educate each other on what happens at each level of care. Team worked together to standardize educational materials and improve communication between providers. Internal measures include revising educational process and improving medication reconciliation. Eligible patients are referred to Pennsylvania Area Agencies on Aging for follow-up after discharge.
mesh_terms: D019090:Case Management / Q000458:organization & administration; D003151:Community Health Centers; D003266:Continuity of Patient Care / Q000458:organization & administration*; D003299:Cooperative Behavior; D006126:Group Processes; D006780:Hospitals, Rural; D006801:Humans; D019982:Organizational Case Studies; D010359:Patient Readmission / Q000706:statistics & numerical data; D010414:Pennsylvania; D058996:Quality Improvement / Q000458:organization & administration