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An Approach to Care Management for High-Risk Patients: Page 3 of 3

An Approach to Care Management for High-Risk Patients: Page 3 of 3

Step 5: Perform after-hospital care

Hospital readmissions are unpleasant for your patients, are expensive, and may place your patients at increased risk for morbidity. Many hospital readmissions can be avoided if you:

• Use census information to be sure you know which patients in your panel are in a hospital or skilled nursing facility

• Communicate promptly with a hospitalist or attending physician, ideally verbally, at the time of discharge

• Request a discharge care plan and summary

• Schedule post-hospital visits with primary-care physician within 72 hours of discharge

• Reconcile medication

• Educate the patient on preventive measures for the future

• Engage caregivers and family members in after-care instructions

Providing high-quality care to fragile Medicare members requires an entire ecosystem of health professionals. The best care we can give them is holistic and patient-centered care rather than costly and episodic. The primary-care physician plays a crucial role as the center of this ecosystem, advocating for the patient's health and coordinating all of the right resources to get them the care they need.

Robert Grossman, MD, MBA, chief medical officer at Transcend, is a board-certified physician in internal and critical care medicine. Dr. Grossman obtained his medical degree from New York Medical College, his master's degree in business administration from the University of North Carolina, and his Bachelor of Science degree in psychology from Hamilton College. He can be reached at rgrossman@transcendphm.com


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