Avoidable hospital admissions are a key patient safety and quality concern for patients returning home from hospitals and skilled nursing facilities. A significant cause of preventable readmissions is poor communication and coordination of care during transitions. Transitions between care settings are vulnerable periods for all patients, but especially older adults and those with multiple comorbidities. Transitions include admissions and discharges within and between acute-care hospitals, skilled nursing facilities, long-term care facilities, long-term acute-care hospitals, assisted living facilities, and home.
All too often, poor coordination between the acute setting and primary care provider results in poor longitudinal care planning. Fewer than 50% of patients see their primary care providers within 2 weeks of hospital discharge.
We offer comprehensive programs to enhance care during transitions between settings can reduce not only 30-day hospital readmissions but also readmissions for the entire year after the initial hospitalization.