Care coordination measures of a family medicine residency as a model for hospital readmission reduction.

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.