Readmission study leads to continuum of care.

A "continuum of care" project has been developed with the goal of decreasing the rate of unplanned readmissions. In addition to reducing these readmissions from 5.0% to 3.45% annually, the project has fostered excellent communication among nurses, social workers and physicians. Also, many patients are communicating more effectively with their health care providers. Our patient care delivery system has become an integrated, collaborative model through meeting patient care needs beyond the walls of our facility.