title: Team approach to readmission reductions pays off.
abstract: Our Lady of the Lake Regional Medical Center has avoided readmission penalties for Medicare patients by launching a series of initiatives that tailor interventions to the individual patient. Members of the multidisciplinary team communicate throughout the day during morning rounds and daily huddles, and share information on patients and their caregivers that the case manager can use to develop a discharge plan. Care navigators in some areas provide extra assistance and post-discharge follow-up for patients who need it. Every patient gets at least one follow-up phone call after discharge.
mesh_terms: D019090:Case Management / Q000458:organization & administration; D003299:Cooperative Behavior; D004469:Economics, Hospital; D008145:Louisiana; D019982:Organizational Case Studies; D062526:Patient Navigation; D010359:Patient Readmission / Q000191:economics