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preventing hospitalization; reducing hospitalization
Management:
1) frequent in-person meetings with patients
2) in-person meetings with physicians
3) a communications hub for physicians
4) evidence-based patient education
5) emphasis on medication management
6) proactive transitional care
7) multidisciplinary intervention that includes home visits [3]
References
- Geriatric Review Syllabus, 8th edition (GRS8)
Durso SC and Sullivan GN (eds)
American Geriatrics Society, 2013
- Brown RS, Peikes D, Peterson G, Schore J, Razafindrakoto CM.
Six features of Medicare coordinated care demonstration
programs that cut hospital admissions of high-risk patients.
Health Aff (Millwood). 2012 Jun;31(6):1156-66
PMID: 22665827
- NEJM Knowledge+ Question of the Week. May 7, 2019
https://knowledgeplus.nejm.org/question-of-week/1685/
- Linertova R, Garcia-Perez L, Vazquez-Diaz JR et al.
Interventions to reduce hospital readmissions in the elderly:
in-hospital or home care. A systematic review.
J Eval Clin Pract 2011 Dec; 17:1167.
PMID: 20630005