One-third of all Medicare beneficiaries are rehospitalized 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. Additional community interventions (within office practices, home care, and skilled nursing facilities) that have been proven to be effective in eliminating rehospitalizations will also be described.

      After this presentation you will be able to:

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