Discharges and Readmissions: Advancing Effective Coordination of Care

Video Runtime: 61 Minutes; Learning Assessment Time: 33 Minutes

Transitioning from acute care to post-acute care may contribute to the development of negative healthcare outcomes. Research indicates that as many as 20 percent of patients experience adverse events within three weeks of discharge, nearly three-quarters of which could have been prevented or ameliorated. Members of the transdisciplinary receiving team within post-acute environments of care may not be aware of all previously provided interventions and diagnostic evaluations performed during hospitalizations. With as many as 40 percent of patients discharged with test results pending and plans for further workups not communicated appropriately, patients may face a discoordination of care that often compromises the ability to promote the achievement of desired outcomes.

Effective and efficient care coordination across the discharge and admission process is vital to advancing patient safety, promoting the achievement of desired patient outcomes, and maximizing reimbursement for provided services. This course will offer an overview of care coordination and transitional care teams and processes that advance an ability to reduce the rate of potentially preventable emergency department visits and readmissions while supporting initiatives to return the patient to their community. This course is applicable to physical therapists, occupational therapists, speech-language pathologists, nurses, social workers, and case managers. Last Reviewed: November 2024