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Teamwork eases transitions of care for the elderly

CU and the UCH Seniors Clinic rein in readmissions with communication, coordination

The transition from the hospital to another facility or even home can be challenging for patients under the best of circumstances, but it’s often especially difficult for the elderly. Many of them have complex medical conditions and medication regimens that put them at higher risk of readmission. The Seniors Clinic at University of Colorado Hospital is part of an initiative to support its patients after discharge by marrying technology with old-fashioned communication.

The initiative is a joint effort between the clinic and Ambulatory Health Promotion (AHP) – a patient outreach program that is part of the University of Colorado School of Medicine’s Office of Value-Based Performance. The overall goal of AHP is to provide preventive care and chronic disease management to UCH patients through a variety of strategies.

The AHP-Seniors Clinic initiative aims to coordinate care for elderly patients discharged from UCH to go home or to a community provider. The foundation is the Epic electronic health record (EHR), which AHP uses to identify the patients, said Lisa Schilling, MD, MSPH, director of the program.

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