Implemented Strategies to Reduce Hospital Readmissions and Unnecessary Hospital Transfers

Integrate evidence-based approaches to existing practices.​

Improve communication between caregivers and care providers.​

Early identification of condition changes & treatment in the facility when appropriate. 

Enable advanced care planning and improve palliative care delivery.

Reconcile the patient's medications on admission to a nursing home and again before discharge.

Improve patient transition to home or next provider of service. ​