Relative Patient Benefits of a Hospital-PCMH Collaboration Within an ACO to Improve Care Transitions

"1. Inpatient medication safety interventions~2. Inpatient discharge advocate~3. Structured visiting nurse (VNA) appointments~4. Post-discharge phone call by primary care personnel within 2 business days of discharge~5. Structured post-discharge clinic appointment with PCP and other PCMH personnel within 2 weeks of discharge~6. Improved communication between inpatient and primary care teams~7. High-risk patients will receive additional interventions as needed:~ 1. Home pharmacist visit~ 2. Enrollment in the Partners integrated Care Management Program (iCMP)~ 3. Enrollment in telemedicine programs for patients with CHF~ 4. Palliative care consultation regarding goals of care~8. Novel health information technology to facilitate communication and transfer of clinical information"