title: Hospitals, Council on Aging partner to reduce readmissions.
abstract: Carondelet Health Network and the Pima Council on Aging have partnered to provide follow-up care coordination for at-risk patients who are being discharged from the hospital. Carondelet nurses visit patients in the hospital to assess them for eligibility and make at least one home visit to conduct medication reconciliation, educate them on self-management, and reinforce discharge education on signs and symptoms that indicate they should call their doctor. Care coordinators/social workers from the Pima Council on Aging are called coaches and help patients access social services, visit them in their homes as often as needed, and provide support in following the treatment plan. The Transitional Care team developed patient education tools based on color-coded zones for each diagnosis to alert patients on what to do when their condition changes.
mesh_terms: D000368:Aged; D019090:Case Management / Q000458:organization & administration*; D015897:Comorbidity; D003266:Continuity of Patient Care / Q000458:organization & administration*; D003299:Cooperative Behavior; D006764:Hospitals, Community / Q000458:organization & administration*; D006801:Humans; D006278:Medicare; D019982:Organizational Case Studies; D010351:Patient Discharge; D015397:Program Evaluation; D014481:United States