Hosp Case Manag. 2015 Jan;23(1):7-8.
A team effort at Holzer Health System helped reduce the rate of all-cause readmissions by 20%. The case management department was redesigned so care managers and social workers report to the same person, care managers are housed on the unit, and the care management team works weekends, holidays, and evenings. The goal is for at-risk patients to have at least one visit from a home health nurse. When patients are being transferred to a post-acute facility, the vice president for post-acute care services calls the director of nursing at the receiving facility with information on the patient.
霍尔泽医疗系统的团队协作使全因再入院率降低了20%。病例管理部门进行了重新设计，护理经理和社会工作者向同一人汇报工作，护理经理入驻病房，护理管理团队在周末、节假日和夜间工作。目标是让高危患者至少接受一次家庭健康护士的探访。当患者被转至急性后期护理机构时，急性后期护理服务副总裁会将患者信息告知接收机构的护理主任。
