Hosp Case Manag. 2012 Jul;20(7):108-9.
The University of Michigan Hospitals and Health Centers has reduced its overall readmission rate to 17.4% with a multi-pronged program that concentrates on patients who are under age 65 but high utilizers of healthcare services. Case managers provide high-intensity care coordination for about 25 patients at a time with complex medical and psychosocial needs. They visit them in the hospital and often accompany them to primary care visits. Non-clinical patient care associates make follow-up calls to less acute patients after a hospital discharge.
密歇根大学医院及健康中心通过一项多管齐下的项目将其总体再入院率降至了17.4%，该项目专注于65岁以下但医疗服务高利用率的患者。病例管理人员一次为约25名有复杂医疗和心理社会需求的患者提供高强度的护理协调。他们在医院探访患者，并经常陪同患者去看初级护理。非临床患者护理助理在患者出院后对病情较轻的患者进行随访。
