title: Clinic visits, CM interventions fill gaps in care after discharge.
abstract: At-risk patients who are being discharged from Torrance (CA) Memorial Medical Center are referred to the Care Coordination Clinic for follow-up care and/or receive care coordination services from an ambulatory care-manager. At the Care Coordination Clinic, a physician or nurse practitioner reviews the discharge plan, reinforces discharge education, conducts medication reconciliation, and communicates with the patient's primary care physician. Patients are usually seen at the clinic only once, then followed by an ambulatory care manager unless they are having home health services. Then the care manager picks up after the patient is discharged from home health. The Care Coordination Clinic also sees patients who have not been hospitalized, but who have been referred by the emergency department staff or community physicians because their chronic conditions are deteriorating or they need palliative care.
mesh_terms: D000553:Ambulatory Care; D019090:Case Management / Q000458:organization & administration*; D006801:Humans; D010351:Patient Discharge