Hosp Case Manag. 2014 Mar;22(3):25-7.
As attention focuses on preventing readmissions, hospitals must improve their internal processes and forge relationships with post-acute providers. Patients are most vulnerable when they move between levels of care. Often, readmissions occur when the receiving provider doesn't have adequate information to continue the plan of care. Case managers should take the time to identify patients' needs and risks for readmission and communicate clearly with the patient and caregivers about what they need to do.
随着注意力集中在预防再入院上，医院必须改进其内部流程，并与急性后期护理服务提供商建立关系。患者在不同护理级别之间转换时最为脆弱。通常，当接收方提供商没有足够信息来继续护理计划时，就会发生再入院情况。病例管理人员应花时间确定患者的需求和再入院风险，并就患者及其护理人员需要做的事情与他们进行清晰沟通。
