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

CONCLUSIONS: 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. PMID: 29087639 [PubMed - in process]
Source: The American Journal of Managed Care - Category: Health Management Authors: Tags: Am J Manag Care Source Type: research