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Curbing Admissions and Readmissions Through Care Coordination

Date: Tuesday, August 20, 2013

Time: 12:00 AM ET

Speakers from Oregon Health & Science University (OHSU) and the General Medicine Clinic at San Francisco General Hospital (SFGH) described their innovative, team-based programs to keep patients from coming back to the hospital.

OHSU, an inpatient hospital that discharges a large number of heart failure (HF) patients, discussed how their HF program uses team resources to implement “hot spotting” and “health buddies” interventions.

The SFGH team then discussed best practices and team roles that can be used in a primary care-based management program. SFGH’s General Medicine Clinic (GMC) received a 2013 Gage Award in recognition of the program’s success.



Jayne Mitchell, ANP-BC
Nurse Practitioner, Congestive Heart Failure
Oregon Health & Science University

Dr. Elizabeth Davis
Physician Lead, General Medicine Clinic Care Management Program
San Francisco General Hospital

Fern Ebeling, RN
Care Management
General Medicine Clinic
San Francisco General Hospital

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