Montefiore Medical Center
If I do my job well then I can help avoid the need for roughly one in eight admissions of our Medicare patients.
Concerns
My primary area of concern in my new care coordination role is identifying gaps in care – and figuring out how to reduce them.
CLG Helps Me
Pinpoint gaps in care and, for those at greater risk, begin to understand why – so I can help prevent readmissions

Nurse

I am a care coordinator. I search out gaps in care and figure out how to reduce them. Right now I am concentrating on readmissions to the hospital within 30 days of discharge. More than 17% of hospital discharges for Medicare patients result in a readmission. I understand from the health care literature that ¾ of these hospital readmissions are avoidable through proper care and prevention. If I do my job well then I can help avoid the need for roughly one in eight admissions of our Medicare patients. To do this I require timely information which only CLG can provide.

Nurse and patientMy focus on readmissions is important for at least two reasons. One is financial; we do not get reimbursed from CMS for these 30-day readmissions. The other is personal. These readmissions may be for people whose need to be in the hospital can be prevented. If they do get admitted it impacts them and their family. Think of how many people I can really help!

As a nurse, my role with a patient no longer ends when the patient leaves the hospital and gets into the car. I am now calling patients shortly after they are discharged to see how they doing at home. I need to know the level of pain that each patient is having and whether or not they are following the care plan.

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