Hosp Case Manag. 2014 Nov;22(11):150, 155-6.
Montefiore Medical Center's collaboration with five skilled nursing facilities on improving transitions has resulted in a drop in 30-day readmission rates to 15%. A multidisciplinary team visited nursing facilities in the area, reviewed readmission rates and Nursing Home Compare information and chose five facilities that are in locations convenient to Montefiore patients. Montefiore representatives met with each facility individually and helped them adapt the INTERACT program (Interventions to Reduce Acute Care Transfers), a quality improvement program designed to improve care and reduce potentially avoidable readmissions. Now representatives from all five nursing facilities meet with the Montefiore team monthly and collaborate on ways to improve transitions.
蒙特菲奥里医疗中心与五家专业护理机构合作改善转诊流程，使得30天再入院率降至15%。一个多学科团队走访了该地区的护理机构，审查再入院率及“护理院比较”信息，并挑选了五家对蒙特菲奥里医疗中心患者来说地理位置便利的机构。蒙特菲奥里医疗中心的代表分别与每家机构会面，帮助它们采用“INTERACT项目”（减少急性护理转诊干预措施），这是一个旨在改善护理并减少潜在可避免再入院情况的质量改进项目。现在，五家护理机构的代表每月都与蒙特菲奥里医疗中心团队会面，并就改善转诊流程的方法展开合作。
