Abstract
There are no protocols for case management referrals of patients at risk for social hospital admissions by their outpatient providers. Social admissions lead to adverse outcomes such as delirium, infections, polypharmacy, falls, functional dependence, pose a resource and financial strain on organizations, and are antithetical to patient-centered care. Timely case management intervention may prevent these hospitalizations by establishing a plan for future care needs. Project activities included the analysis of retrospective admission data from a N.H. community hospital, collaboration with interdisciplinary colleagues among and between both inpatient and outpatient settings, and an evaluation of best practices from the literature, resulting in several recommendations, including earlier identification of high-risk patients for whom referrals to case management could improve outcomes. Successful implementation will be evaluated by tracking the potential of a reduction of avoidable days, unreimbursed care, emergency department boarding, use of chemical and physical restraints, falls, infections and improved outcomes.
Project Type
Capstone
College or School
College of Professional Studies Granite Division
Program or Major
Nursing Health Care Leadership
Date
Winter 2023
Recommended Citation
Blondeau, Elizabeth, "Early Case Management Involvement for Long-term Care Planning in the Primary Care Setting to Reduce Avoidable Social Admissions in High-Risk Patients" (2023). M. S. in Nursing Health Care Leadership. 6.
https://scholars.unh.edu/ms_nursing_health_care_leadership/6