Chronic care management: Transitional care models for readmission reduction

Readmission Reduction;Transitional Care;Disease Management Clinic;Value Based Purchasing;Heart Failure;Healthcare Leadership & Management

Doyle, DanielBoyd, Cynthia ;

Johns Hopkins University

关键词: Readmission Reduction;    Transitional Care;    Disease Management Clinic;    Value Based Purchasing;    Heart Failure;    Healthcare Leadership & Management;   

Others  :  https://jscholarship.library.jhu.edu/bitstream/handle/1774.2/59976/DOYLE-DISSERTATION-2018.pdf?sequence=1&isAllowed=y

瑞士|英语

来源: JOHNS HOPKINS DSpace Repository

【 摘 要 】

Growing pressure on hospital systems to reduce readmissions, including efforts by the Centers for Medicare & Medicaid Services (CMS) to penalize hospitals with high readmission rates, coupled with limited inpatient bed and staff availability have placed even more focus within health systems on appropriately managing patients with chronic conditions in the most cost-effective setting. Traditional readmission reduction programs have centered on efforts within the acute care setting, however continued improvement requires leveraging transitional care programs to ensure health care continuity, prevent poor outcomes and promote safe and timely transfer of patients from the inpatient to outpatient setting. This dissertation examines the potential impact of two such transitional care programs and their effects on hospital readmissions: establishing patients in a disease management clinic and the development of a post-discharge in-home visit.