Did you ever wonder how your stroke patient fared after they were discharged from the acute care hospital? Does the post-acute care provider the patient discharged to help or hurt your hospital outcomes? In this session, learn how a large national network of inpatient rehabilitation hospitals helps improve long term outcomes; avoiding unnecessary emergency room visits, reducing readmissions, avoiding falls, and maximizing patients’ health and well-being. You will hear details about predictive analytic models that help clinicians determine the risk of readmissions that may occur during the inpatient rehabilitation stay or may occur in the days following discharge. You will also learn about progress on the newest predictive algorithm that helps identify patients at risk for falls and how all of these predictive models have contributed to the design and implementation of clinical interventions and other strategies to mitigate these risks and improve outcomes for patients. Case managers play a crucial role in the success of these programs and their contribution will be discussed in detail.

OBJECTIVES:

1. Gain a better understanding of basic medical necessity for an inpatient rehabilitation stay
2. Identify both clinical and non-clinical risk indicators that increase probability of a readmission
3. Discuss how avoiding readmissions is an interdisciplinary process