title: Program bridges acute, post-acute care.
abstract: Torrance (CA) Memorial Health System instituted Total Wellness Torrance, a multi-pronged approach to reducing preventable readmissions. The hospital created a post-acute network of providers that agree to participate in quality improvement initiatives and who meet regularly with hospital representatives. Care Transitions staff meet weekly with post-acute providers to collaborate on patient care and the discharge plan. The hospital operates a Care Coordination Center, a post-discharge clinic where clinicians go over the treatment plan and conduct medication reconciliation.
mesh_terms: D002140:California; D003266:Continuity of Patient Care / Q000592:standards; D003422:Critical Care; D006801:Humans; D019982:Organizational Case Studies; D010359:Patient Readmission; D011785:Quality Assurance, Health Care / Q000458:organization & administration; D012046:Rehabilitation