title: Improving patient outcomes with better care transitions: the role for home health.
abstract: Patients, particularly the old and frail, are especially vulnerable at the time of hospital discharge. Fragmentation of care, characterized by miscommunications and lack of follow-up, can lead to oversights in diagnosis and management. The frequent result is avoidable rehospitalization. Amedisys, a home health and hospice organization, created and tested a care transitions initiative for its impact on patients' quality of life and avoidable rehospitalizations. The initiative was carried out in three academic institutions with 12 months of observation. The results suggested reduced hospital readmissions and a critical role for the home health industry in improving patient outcomes and reducing costs.
authors: Amedisys, Inc, 5959 S Sherwood Forest Boulevard, Baton Rouge, LA 70816, USA. michael.fleming@amedisys.com
authors: Michael O
authors: MO
authors: Fleming
authors: Tara Trahan
authors: TT
authors: Haney
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003266:Continuity of Patient Care / Q000592:standards* / Q000639:trends; D003704:Dementia; D004636:Emergency Service, Hospital / Q000191:economics / Q000706:statistics & numerical data; D005260:Female; D016330:Frail Elderly; D006333:Heart Failure / Q000175:diagnosis / Q000628:therapy; D006699:Home Care Services / Q000592:standards* / Q000639:trends; D006801:Humans; D007400:Interprofessional Relations; D008017:Life Expectancy / Q000639:trends*; D006278:Medicare / Q000191:economics / Q000639:trends; D010351:Patient Discharge / Q000592:standards* / Q000639:trends; D010353:Patient Education as Topic / Q000379:methods; D010359:Patient Readmission / Q000592:standards* / Q000706:statistics & numerical data; D018802:Patient-Centered Care / Q000592:standards* / Q000639:trends; D011157:Population Dynamics / Q000639:trends; D014481:United States