Hosp Case Manag. 2012 Jun;20(6):91-2.
A clinical integration case manager acts as heart failure liaison at Hartford Physician Hospital Organization in Hartford, CT. She coordinates care between the hospital, Hartford Physicians Association, home health agencies, and skilled nursing facilities. The initiative has kept the readmission rate at 11% to 13%. The liaison attends heart failure physician rounds and receives most referrals during the rounds. She meets the patients in the hospital, then contacts them by phone as often as necessary for 30 days or more after discharge. She collaborates with staff at the home health agencies and skilled nursing facilities to ensure that patients are receiving the care and education they need.
一名临床整合病例经理在康涅狄格州哈特福德市的哈特福德医师医院组织担任心力衰竭联络人。她负责协调医院、哈特福德医师协会、家庭健康机构和专业护理机构之间的护理工作。该举措使再入院率保持在11%至13%。这位联络人参加心力衰竭医生的查房，并在查房期间接收大多数转诊。她在医院与患者见面，出院后还会根据需要尽可能频繁地给他们打电话，持续30天或更长时间。她与家庭健康机构和专业护理机构的工作人员合作，以确保患者得到他们所需的护理和教育。
