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.
