title: Safety net hospital, community providers collaborate to improve transitions.
abstract: A Care Transitional Task Force at San Francisco General Hospital created a cross-continuum program that has reduced readmissions and increased timely primary care visits for discharged patients. A basic bundle of services includes communication between inpatient and outpatient providers, providing the right information to the next level of providers, and giving patients and family members the right level of education. Transitional care nurses work with heart failure patients of any age and patients over 55 with chronic obstructive pulmonary disease, diabetes, renal failure, or who are recovering from a myocardial infarction. The nurses work closely with patients and family members during the hospital stay and follow up weekly for 30 days after discharge.
mesh_terms: D003153:Community Health Services; D003299:Cooperative Behavior; D004636:Emergency Service, Hospital; D011203:Poverty; D011787:Quality of Health Care; D014481:United States