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- Hosp Case Manag. 2013 Apr 1;21(4):50-1.
AbstractBassett Medical Center's readmission project cut 30-day readmissions by up to 70% for the highest-risk patients and resulted in the medical center being one of only 20 hospitals in New York State that did not incur readmission penalties from the Centers for Medicare & Medicaid Services. The care coordination team includes case managers, social workers, and patient service coordinators who set up post-acute services and call at-risk patients within a day of their discharge. Case managers round with physicians and refer patients who have psychosocial needs to the social workers for follow up. Continuing care coordinators at primary care offices attend multidisciplinary rounds with the hospital team and receive detailed information about the hospital stay.
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