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A prediction algorithm (the Preadmission Readmission Detection Model or PREADM) uses electronic medical record and administrative data to derive a risk score and identify high-risk patients. Develop and implement an ongoing strategy to prevent 30-day hospital readmissions among high-risk elderly patients insured by Clalit Health Services. CC-MAP nurses help patients access social services.

 

Main components of the intervention include a comprehensive assessment of patient and family needs; formulation of a coordinated care plan based on integrated care guideline summaries; an action plan for patients; caregiver support including self-

 

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