title: Talk to each other to improve patient care, reduce readmissions.
abstract: Lack of communication prevents clinicians from delivering coordinated care, which often results in adverse effects on the patient and the hospital's bottom line. Healthcare providers need to move from a fragmented system to an integrated one where entities across the continuum communicate and work together to improve patient care. Case managers should develop strong working relationships with post-acute providers, case managers at community organizations, and their counterparts at health plans. Multidisciplinary rounds are essential for breaking down organizational silos and ensuring that all clinicians are on the same page.
mesh_terms: D019090:Case Management; D003142:Communication; D006801:Humans; D005791:Patient Care; D010359:Patient Readmission; D058996:Quality Improvement