title: Study: interventions help prevent readmissions.
abstract: In a study by the Bronx Collaborative, patients who received two or more interventions by a dedicated care transition manager had a 17.6% readmission rate compared to a rate of 26.3% for patients who received the current standard of care. Three hospital systems and two health plans collaborated to develop the pilot project. Care transition managers, whose only job was facilitating transitions, visited patients in the hospital and followed up within 48 hours after discharge and again 14 days after discharge. The care transition managers educated the patients on their treatment plan, gave them a personalized booklet with details of their treatment plan, and followed up to answer questions and concerns and make sure they were following the plan.
mesh_terms: D014487:Centers for Medicare and Medicaid Services, U.S. / Q000592:standards*; D015897:Comorbidity; D003266:Continuity of Patient Care / Q000458:organization & administration* / Q000592:standards; D006801:Humans; D007373:Interinstitutional Relations; D009518:New York; D010351:Patient Discharge / Q000592:standards*; D010353:Patient Education as Topic / Q000379:methods / Q000458:organization & administration* / Q000592:standards; D010359:Patient Readmission / Q000592:standards* / Q000706:statistics & numerical data; D010865:Pilot Projects; D011369:Professional-Patient Relations; D018570:Risk Assessment; D012959:Socioeconomic Factors; D014481:United States