As a result of poor coordination of care, one in five Medicare patients is readmitted within 30 days of discharge from the hospital, according to a new infographic by Primaris.
The infographic also examines the level of post-discharge care for Medicare beneficiaries who are re-admitted and the cost of these readmissions.
Health risk stratification is scalable—whether grouping diabetics in a single practice without an EMR or drilling down to an ACO’s subset of medication non-adherent diabetics with elevated HbA1cs who lack social supports. That’s the experience of Ochsner Health System, whose scaling and centralization of risk stratification and care coordination protocols across its nine-hospital system drive ROI and improve clinical outcomes and efficiency.
Scalable Models in Health Risk Stratification: Results from Cross-Continuum Care Coordination explores Ochsner’s approach, in which standardized scripts, tools and workflows are applied along the care continuum, from post-hospital and ER discharge telephonic follow-up to capture of complex cases for outpatient management.
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Tags: Care Coordination, Hospital Readmissions, post hospital discharge
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