When patients leave the hospital, one key factor often determines whether they'll soon need to be readmitted: how well they follow their discharge instructions.
Many organizations across the country have learned that patient care is more effective when providers work together. One means of accomplishing this goal is by performing patient rounds using teams that include a number of different practitioners, from physicians and nurses to case managers and pharmacists.
Successful programs to reduce preventable hospital readmissions range from the transitional care model created by Mary Naylor, PhD, FAAN, RN, a nurse researcher at the University of Pennsylvania, to Project RED, created by the Commonwealth of Massachusetts. Kathleen Heery, MS, RN, CCM, and Cheryl Pacella, DNP(c), HHCNS-BC, CPHQ, the homecare consultant and quality advisor at CAP Consulting, LLC, discussed the secrets to their success during "Reducing Readmissions by Improving Transitions in Care," an HCPro webcast.
