Care coordination measures of a family medicine residency as a model for hospital readmission reduction.
The processes of care coordination of patient transition from hospital to outpatient settings are an integral part of the Patient-Centered Medical Home. We report a cooperative initiative between our admission hospital and family medicine residency to analyze the discharge process using the Agency for Healthcare Research and Quality's Re-engineering Discharge initiative, focusing on efficient information transfer and communication with discharged patients to insure rapid follow-up in the clinic. Our project yielded markedly reduced readmission rates compared with both local hospital and national rates.
Director of Patient-Centered Outcomes Research, Southern Illinois University School of Medicine, Family Medicine, Decatur Family Medicine Residency, 250 W Kenwood Ave, Decatur, IL 62526. E-mail: wmathews@siumed.edu.
Wayne A
WA
Matthews
D057189:Checklist; D003266:Continuity of Patient Care / Q000458:organization & administration*; D005194:Family Practice / Q000193:education*; D006801:Humans; D007087:Illinois; D007396:Internship and Residency / Q000458:organization & administration*; D017146:Models, Organizational; D010351:Patient Discharge; D010359:Patient Readmission / Q000706:statistics & numerical data*; D061214:Patient Safety