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Implemented Strategies to Reduce Hospital Readmissions and Unnecessary Hospital Transfers

1.  Integrate evidence-based approaches to existing practices

2.  Improve communication between care givers and care providers

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

4.  Enable advance care planning and improve palliative care delivery


5.  Reconcile patient's medications on admission to nursing home, and again before discharge


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

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