Presenters: Patricia A. Rutherford, RN, MS, Vice President, Institute for Healthcare Improvement; Edward Wagner, MD, MPH, Director, MacColl Institute, Group Health Cooperative of Puget Sound

    One-third of all Medicare beneficiaries are re-hospitalized within 90 days of discharge to the community, and many of these readmissions are associated with significant failures of the health care system. This session will explore strategies to optimize discharge planning, preparations, and handoffs to community providers. Community interventions within office practices and home care that have been proven to be effective in optimizing the health of individuals with chronic conditions and eliminating re-hospitalizations will also be described.
    After this presentation you will be able to:

• Describe promising changes to create an "ideal transition home" for patients who have been hospitalized.
• Identify key components of an ideal post-hospitalization care delivery system to optimize care for chronically ill patients and prevent readmissions.
• Describe high-leverage changes and strategies used in clinical office practices and in home care that help prevent unnecessary readmissions to the hospital.