This course will discuss the case manager’s role as the patient is moving from the hospital into another setting of care, whether through transfer or discharge. It will also focus on how to ensure these transitions are seamless and successful, as well as how to prevent avoidable readmissions, particularly among high-risk patients leaving the hospital. A readmission prevention program should include several components. One is a risk assessment to identify patients at risk for a readmission. Also key are strategies that take into account not only medical factors, but social, cultural, and behavioral considerations as well—all of which may present barriers to a successful discharge.
At the completion of this course, the student will be able to: