title: Team effort reduces readmission rate by 20% in two years.
abstract: A team effort at Holzer Health System helped reduce the rate of all-cause readmissions by 20%. The case management department was redesigned so care managers and social workers report to the same person, care managers are housed on the unit, and the care management team works weekends, holidays, and evenings. The goal is for at-risk patients to have at least one visit from a home health nurse. When patients are being transferred to a post-acute facility, the vice president for post-acute care services calls the director of nursing at the receiving facility with information on the patient.
mesh_terms: D019090:Case Management / Q000458:organization & administration*; D003266:Continuity of Patient Care / Q000458:organization & administration*; D006801:Humans; D009820:Ohio; D019982:Organizational Case Studies; D010359:Patient Readmission / Q000706:statistics & numerical data*; D058996:Quality Improvement; D012947:Social Work