Managing High-Risk and Chronic Condition Patients

With just a small number of patients making up a large portion the nation's medical expenses, targeting these "high-risk" groups is vital to controlling healthcare costs and reducing utilization. This eBook will examine strategies that healthcare organizations are implementing post-discharge to manage vulnerable patient populations.

Topics may include:

  • Discharge planning: Whether a patient is discharged to his or her home, rehab facility or a nursing home, it’s critical that your hospital’s discharge planning process ensures a smooth transition to the next level of care. We’ll explore discharge models that have improved care coordination and reduced avoidable readmissions.
  • Care improvement opportunities: Strategies and best practices to improve care for the most vulnerable patients, such as those with multiple chronic conditions and those at risk for falls or heart failure.
  • Multi-disciplinary approaches that improve care delivery: Examples of integrated care at its best and the benefits of care coordinators, care coordination teams, e-care options and post-discharge communication plans.
  • Risk factors that can lead to high readmission rates. Red flags for readmissions and factors that can cause them, such as communication breakdowns, early discharges and staff shortages.