title: Care coordination cuts admissions, ED visits, LOS.
abstract: Gundersen Health in La Crosse, WI, has decreased the length of stay by 46% and unplanned admissions or emergency department visits by 64% through an integrated care coordination program that focuses on the most complex patients. Care coordinators who are nurses or social workers follow at-risk patients through the continuum, interacting with them face-to-face in the clinic or hospital and following up by telephone. Patients are identified for the program using a two-pronged tool that assesses both healthcare and psycho-social needs. Care coordinators follow the patients for as long as a year.
mesh_terms: D019091:Critical Pathways; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D006801:Humans; D007902:Length of Stay / Q000639:trends*; D019982:Organizational Case Studies; D010343:Patient Admission / Q000639:trends*; D010348:Patient Care Team; D014922:Wisconsin