title: Collaborate across the continuum to ensure successful transitions.
abstract: As attention focuses on preventing readmissions, hospitals must improve their internal processes and forge relationships with post-acute providers. Patients are most vulnerable when they move between levels of care. Often, readmissions occur when the receiving provider doesn't have adequate information to continue the plan of care. Case managers should take the time to identify patients' needs and risks for readmission and communicate clearly with the patient and caregivers about what they need to do.
mesh_terms: D003266:Continuity of Patient Care; D003299:Cooperative Behavior; D006801:Humans; D010351:Patient Discharge; D014481:United States