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Dedicated care coordinators employed and trained by AIC and based at the respective hospitals coordinated discharge planning and care transition for patients from the hospitals to community settings.
Internationally, short hospital lengths of stay and a high demand for post-acute care have led to new models of care for older people that offer coordinated discharge, ongoing support and often a focus on functional restoration.
An increasing demand for acute care services due in part to rising proportions of older people and increasing rates of chronic diseases has led to new models of post-acute care for older people that offer coordinated discharge, ongoing support and often a focus on functional restoration.
Comprehensive geriatric screening and coordinated discharge planning initiatives designed to improve clinical outcomes in older emergency patients have provided inconclusive results.
This study was conceived to test whether coordinated discharge and post-discharge care could reduce re-hospitalizations and use of resources in patients with COPD.
The second hospital (St. Franciscus Gasthuis, Rotterdam) offers care with coordinated discharge and hospital replacement care (through care hotel "Aafje") and without follow up in primary care.
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Still, the report noted, inmate records were often "chaotic and disorganized," and "poor communication among the many individuals" coordinating discharge plans left too many inmates facing release without community-based help for their illnesses.
The new effort to coordinate discharge planning is aimed primarily at Rikers Island inmates serving three-month to one-year jail terms, a small segment of a general inmate population consisting mainly of detainees awaiting court dates who leave the jail within a week.
Nearly all discharge planning policy/guidelines requires a designated person in coordinating discharge [ 13, 14, 32, 34].
The protocols all had similar elements, including the assessment of patients, liaising with the patient's carer and other professionals to coordinate discharge and providing follow-up visits or telephone calls.
30 31 Given the clinical risks associated with hospital discharge, it continues to be a national policy priority, 32 with the advice that care transitions should be seen as 'a process not an isolated event' 33 involving the active participation of healthcare and social care professionals, as well as service users and carers, to effectively plan and coordinate discharge.
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