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Hospital-Home Care Collaboration (2.b.viii)

Project Objective

Implementation of an INTERACT™-like program (Interventions to Reduce Acute Care Transfers) in the home care setting to reduce the risk of re-hospitalizations for high-risk patients.

Project Details

Many patients who previously were transferred to skilled nursing facilities are now being discharged to less-restrictive alternatives, primarily their own home. With the many benefits of returning to a known and personal setting, there are the risks of potential non-compliance with discharge regimens, missed provider appointments and less frequent observation of an at-risk person by medical staff. This project puts services in place to address this problem. It may be paired with transition care management, but the service would be expected to last more than 30 days.

Patient Population

Chronically ill and/or high-risk individuals.

Project Information

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