A chart review of frequently readmitted patients revealed that a clear discharge plan was documented in only 68% of cases, highlighting a gap in care coordination.
May signal care coordination gaps in readmitted patients; hypothesis-generating and should not yet change practice.
This project used chart review to evaluate 22 patients labeled as "frequent fliers," each with 4 to 8 readmissions over a 6-month period at a Michigan community hospital. The goal was to identify whether the 4 key elements identified by the Institute for Healthcare Improvement for reducing rehospitalization had been put into place for these patients. It found that a clear discharge plan was only documented for 15 (68%) of the 22 patients. Better coordinated care is warranted.
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Mulder et al. (2011) studied this question.
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