Hosp Case Manag. 2015 May;23(5):58-9.
Phone calls from nurses at Ochsner Health System's Care Coordination Center within 24 to 48 hours after discharge have reduced readmissionsfor at-risk patients who receive calls by 20%. The program was developed as part of Ochsner's accountable care organization and is expanding across the nine-hospital health system. Nurse case managers reinforce discharge education, complete medication reconciliation, and arrange follow-up visits with primary care physicians and specialists. When patients have long-term needs, they are referred to Ochsner's outpatient complex case management program.
奥克施纳健康系统护理协调中心的护士在患者出院后24至48小时内致电，已使接到电话的高危患者再入院率降低了20%。该项目是作为奥克施纳负责医疗组织的一部分而开发的，目前正在这个拥有九家医院的健康系统中推广。护士个案管理员加强出院教育、完成用药核对，并安排与初级保健医生和专科医生的随访。当患者有长期需求时，他们会被转介到奥克施纳的门诊复杂病例管理项目。
