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Department of Medicine

Department of Medicine

  Division of Geriatric Medicine

Clinical


Hospital Care


Leaving the Hospital

Helping patients transition from a hospital care setting to home or to long-term care is key. In an effort to significantly reduce readmissions, all patients discharged to their homes are contacted within 48 hours to review progress, medications, unanticipated problems, and plans for follow up.  Our Division is one of the few in the country that also provides this service to patients discharged to skilled nursing facilities (SNFs), helping ensure that the facility is equipped to provide quality long-term care. 
 
Additionally, the Division is actively taking steps to address the causes of any readmission. We have developed a specialized inter-professional group focused on preventing readmissions:

      1. An inter-professional team meets regularly to analyze root causes of our own readmissions and to identify and address previously unrecognized and unmet needs.

      2. We have decreased readmissions of our Shadyside hospital patients from 19% in FY14 to 10% in FY15.

      3. At UPMC Heritage, we send a comprehensive discharge packet to each SNF patient's primary care physician.. These doctors report that this intervention has improved the continuity of care during such transitions.