Matthews Wayne A
Director of Patient-Centered Outcomes Research, Southern Illinois University School of Medicine, Family Medicine, Decatur Family Medicine Residency, 250 W Kenwood Ave, Decatur, IL 62526. E-mail:
Am J Manag Care. 2014 Nov 1;20(11):e532-4.
The processes of care coordination of patient transition from hospital to outpatient settings are an integral part of the Patient-Centered Medical Home. We report a cooperative initiative between our admission hospital and family medicine residency to analyze the discharge process using the Agency for Healthcare Research and Quality's Re-engineering Discharge initiative, focusing on efficient information transfer and communication with discharged patients to insure rapid follow-up in the clinic. Our project yielded markedly reduced readmission rates compared with both local hospital and national rates.
患者从医院过渡到门诊环境的护理协调过程是“以患者为中心的医疗之家”的一个组成部分。我们报告了我们的收治医院与家庭医学住院医师培训项目之间的一项合作倡议，该倡议使用医疗保健研究与质量局的“重新设计出院流程”倡议来分析出院过程，重点是与出院患者进行高效的信息传递和沟通，以确保在诊所进行快速随访。与当地医院和全国比率相比，我们的项目显著降低了再入院率。
