Results from the first nine months of an intervention with chronic care patients show that
The readmissions program is called Transitions of Care and was conceived in February 2012. It focuses on serving uninsured and low-income Medicaid patients, most of whom are readmitted due to poor control of chronic conditions, according to Jewish Hospital.
Program participants are assigned a nurse who tracks his or her patient for 30 days after discharge, educating the patient on disease management. The nurse also helps the patient make follow-up appointments, understand medication administration and engage in community health resources. In addition, a peer health advisor, who shares a similar background with the patient, speaks daily with the patient and comes by the patient's home each week for four weeks.
The success of Transitions of Care has led to its planned implementation at another Jewish Hospital campus as well as Sts. Mary and
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