title: Team follows at-risk patients after discharge.
abstract: UNC Hospitals in Chapel Hill, NC, has a dedicated team of case managers and pharmacists who evaluate patients who are potentially at risk for readmissions and follows them for 30 days after discharge. The team reviews patients with multiple chronic conditions, a history of admissions, and are taking multiple medications as well as those identified by clinicians on the floor. Case managers and pharmacists visit the patients while they are in the hospital and work with the medical team and inpatient case manager to ensure a safe discharge. Nurses in the hospital's call center telephone patients after discharge to review their medication and answer questions and concerns.
mesh_terms: D019090:Case Management; D003266:Continuity of Patient Care; D003299:Cooperative Behavior; D006785:Hospitals, University; D006801:Humans; D009657:North Carolina; D019982:Organizational Case Studies; D010351:Patient Discharge; D010359:Patient Readmission; D018570:Risk Assessment