title: Extending hospital to the primary care office.
abstract: Using a Centers for Medicare & Medicaid Services Innovation grant, Beth Israel Deaconess Medical Center in Boston launched a program to prevent readmissions. Care transition specialist nurses are assigned to six primary care practices and work with patients in the practice to which they are assigned. They meet patients in the hospital and follow them for 30 days after discharge. The program includes pharmacists who conduct medication reconciliation and work with patients on medication issues, and a social worker who is called in when patients have psychosocial needs.
mesh_terms: D003266:Continuity of Patient Care; D006801:Humans; D024802:Nurse's Role; D010351:Patient Discharge; D011320:Primary Health Care; D014481:United States