QUIP: Reducing Avoidable Readmissions

Case Managment

Transitions of Care

Social Work

Whats New?* Use of Allscripts Care Manager to streamline communications* Create running log of referals made to TOC* Increase awarness of importence of reducing readmissions* Educate interdisplinary team member about efforts being made to reduce readmissions

Need for Action* Fines imposed by CMS for high rate of avoidable readmissions* Patients not reciving proper follow up care, reducing patient satisfaction* Improve patient outcomes and create a healthy community

Working Together* Reduce avoidable readmissions* Follow up and ensure continuity of care* Bridge back to the hospital* Foster trusting patient relationships* Ensure appropriate PCP follow up and connection to patients to community resources

Estrella PerezALTH 501QUIP: Part 3

QUIP: Reducing Hospital Readmissions by Improving Communication between Interdisciplinary Teams