Hosp Case Manag. 2014 Jun;22(6):78, 83-4.
Using a Centers for Medicare & Medicaid Services Innovation grant, Beth Israel Deaconess Medical Center in Boston launched a program to prevent readmissions. Care transition specialist nurses are assigned to six primary care practices and work with patients in the practice to which they are assigned. They meet patients in the hospital and follow them for 30 days after discharge. The program includes pharmacists who conduct medication reconciliation and work with patients on medication issues, and a social worker who is called in when patients have psychosocial needs.
利用医疗保险和医疗补助服务中心创新基金，波士顿的贝斯以色列女执事医疗中心发起了一项预防再入院的项目。护理过渡专科护士被分配到六个初级保健机构，并与他们所分配机构的患者合作。他们在医院与患者见面，并在出院后跟踪他们30天。该项目包括进行用药核对并就用药问题与患者合作的药剂师，以及在患者有心理社会需求时被叫来的社会工作者。
