Enhanced Transition of Care Involving All Aspects of Wellness for the Residents of Lincoln County

Project Term: 12 months; Apr 2017 – Mar 2018
Grant Amount: $44,236

This project will develop a new approach to discharge planning for hospitalized patients that systematically identifies and addresses the social factors that influence outcomes, such as the ability to afford home heating, food, housing, and medications. The hospital will develop a discharge planning tool that identifies these needs and will work with local clinics, and local aid and social service agencies to provide a safety net of services for patients in need at the time of discharge. The project seeks to reduce readmissions related to socioeconomic barriers to health and to increase the acuity of patients seen in the emergency department as well as utilization of local clinics for outpatient care.

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