Preventing Hospital Readmissions through Effective Transitions of Care


Emily Goetzke, MSN, RN
Manager of Population Health and Care Management, Mankato Clinic, Ltd.

Session Details

Date and time: Wednesday, April 5, 1:15-2:15 p.m.
Learning track: Expanding the Team
Learning level: Intermediate

Session Description

Hospital readmissions can be prevented when transitions of care are well managed. The transition from acute care to a skilled nursing home can be particularly challenging because of the importance of continuity of care due to patient complexity. The Mankato Clinic has partnered with an area hospital and with skilled nursing facilities to identify and solve issues related to transitions between the hospital, facility and home. This presentation will describe the development of the partnership and steps taken to promote seamless transitions.

Learning Objectives

At the conclusion of this session, participants will be able to:

  • Describe the challenges with transitions of care to and from skilled nursing facilities.
  • Identify the impact of organizational partnerships to manage transitions of care.
  • Discuss opportunities for partnerships in their own community.