title: Hospital's transition program coordinates care throughout the continuum.
abstract: UnityPoint-St. Luke's Hospital's Transitions Home program has slashed all-cause readmissions to an average of 10% by focusing on making sure patients' needs are met while they are in the hospital and after discharge. An Advanced Medical Team of RN care navigators and social workers works in the outpatient clinic and coordinates care for patients with multiple comorbidities who take multiple medications and are being treated by multiple physicians. The Consistent Care program, overseen by a social worker, links patients who use the emergency department for primary care with a primary care physician. Dedicated care coordinators on each unit have cubicles in the nurses' stations and meet daily with the charge nurse, social worker, and bedside nurse caring for the patient to discuss the goals of care and goals for discharge of each patient on the unit.
mesh_terms: D003266:Continuity of Patient Care; D016519:Hospitals, Religious; D006801:Humans; D007484:Iowa; D019982:Organizational Case Studies; D010351:Patient Discharge; D010359:Patient Readmission