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Gaining ground: care management programs to reduce hospital admissions and readmissions among chronically ill and vulnerable patients
These three case studies from the USA illustrate the potential of
care management programs in addressing preventable hospital admissions
and readmissions by improving care coordination and transitions among
high-risk patients. Study sites included two academic medical centers
and a managed care organisation owned by a home health agency. The sites
employed bundles of interventions involving multidisciplinary teams to
improve provider communication, patient and family education, care
transitions from the hospital, and follow-up ambulatory care.