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Improving care transitions: complex high-utilizing patient experiences guide reform.

Authors
  • Gallagher, Nancy Ambrose1
  • Fox, Donna
  • Dawson, Carrie
  • Williams, Brent C
  • 1 University of Michigan School of Nursing, 400 NIB, #2174, Ann Arbor, MI 48109. E-mail: [email protected]
Type
Published Article
Journal
The American journal of managed care
Publication Date
Oct 01, 2017
Volume
23
Issue
10
Identifiers
PMID: 29087639
Source
Medline
License
Unknown

Abstract

Joint review of clinical characteristics and longitudinal care experiences of high-utilizing, complex patients facilitated movement of historically siloed care management programs from their focus along administrative lines to a longitudinal, patient-centered focus. Decreasing readmission rates among complex patients may require direct linkages with social, mental health, and substance use services outside the healthcare system and improved discharge planning.

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