Post-discharge interventions reduce readmissions by 20%.
Phone calls from nurses at Ochsner Health System's Care Coordination Center within 24 to 48 hours after discharge have reduced readmissionsfor at-risk patients who receive calls by 20%. The program was developed as part of Ochsner's accountable care organization and is expanding across the nine-hospital health system. Nurse case managers reinforce discharge education, complete medication reconciliation, and arrange follow-up visits with primary care physicians and specialists. When patients have long-term needs, they are referred to Ochsner's outpatient complex case management program.
D003266:Continuity of Patient Care / Q000592:standards*; D006769:Hospitals, General; D006801:Humans; D008145:Louisiana; D024802:Nurse's Role; D019982:Organizational Case Studies; D010351:Patient Discharge; D010359:Patient Readmission; D011787:Quality of Health Care