The Patient Safe-D(ischarge) program used standardized tools to educate patients about their discharge needs, test understanding of those needs, and improve medication reconciliation at admission and discharge. A quasi-randomized controlled trial of the program found that it significantly increased patients' understanding and knowledge of their diagnoses, treatment, and required follow-up care.
Social worker/nurse practitioner teams collaborate with a larger interdisciplinary team and primary care physicians to develop and implement individualized care plans for seniors and other high-risk patients. The social worker/nurse practitioner team also proactively manages and coordinates the patient's care on an ongoing basis through regular telephone and in-person contact with both patients and providers.
Under a program known as the Care Transitions Intervention ®, a Transitions Coach ® encourages patients who are transferring from either a hospital or a short-term skilled nursing facility stay to home to assert a more active role in their self-care. The program has consistently reduced 30-day hospital readmissions and costs as well as 180-day hospital readmissions, even in heavily penetrated Medicare Advantage markets in which the reduction of hospital use has been an explicit focus for many years.