Hosp Case Manag. 2012 Sep;20(9):133-4, 139.
Charles Cole Memorial Hospital in Coudersport, PA, slashed its readmission rate by 15.9% by collaborating with post-acute providers and making internal improvements. Community transition team members educate each other on what happens at each level of care. Team worked together to standardize educational materials and improve communication between providers. Internal measures include revising educational process and improving medication reconciliation. Eligible patients are referred to Pennsylvania Area Agencies on Aging for follow-up after discharge.
宾夕法尼亚州库德斯波特的查尔斯·科尔纪念医院通过与急性后护理服务提供商合作并进行内部改进，将再入院率降低了15.9%。社区过渡团队成员就各级护理中发生的情况相互开展培训。团队共同努力使教育材料标准化，并改善服务提供商之间的沟通。内部措施包括修订教育流程和改进用药核对。符合条件的患者出院后会被转介给宾夕法尼亚州老龄问题地区机构进行随访。
