Case Management Focus on Care Transitions Helps to Halve 30-Day Medicare Rehospitalizations

Caldwell UNC Health Care case managers embedded in primary care practices take patient follow-up seriously, calling 90 percent of individuals who visit the ED and almost all discharged from a hospital stay, explains Melanie Fox, director of the Caldwell Physician Network Embedded Case Management program at Caldwell UNC Health Care. In particular, connecting with the recently discharged has helped her organization to reduce 30-day rehospitalizations from 19.16 percent in 2012 to 9.69 percent in 2013. If that crucial transition of care is well managed, all other goals for the patient should fall in line, she notes.

In this audio interview, Ms. Fox describes the 12-point checklist for the recently discharged and offers advice on engaging providers and staff before the case manager even settles in at physician practice.

Melanie Fox will describe how Caldwell UNC Health Care’s managers embedded in primary care practices and work sites are improving the quality of care and reducing healthcare costs during a September 25, 2014 webinar, Embedded Case Management in Primary Care and Work Sites: Referral, Stratification and Protocols, a 45-minute program sponsored by The Healthcare Intelligence Network.


Length: 12:00 minutes

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