When a seriously ill patient has not stabilized in the ICU, the next step may be a long-term acute care hospital like Spaulding Hospital Cambridge — which often is a difficult transition. Six years ago, Spaulding joined nearby Brigham and Women’s Hospital in creating the Integrated Patient Centered Care in Chronic Critical Illness program to provide a seamless transition of care for these patients and their families.

With the increased diversity among today’s hospital patients, case managers must be careful to understand each patient’s culture. People coming from different countries have different expectations of the healthcare system.

A recent study revealed that case management programs helped improve hospital quality and led to reductions in hospital readmission rates. Hospitals that collaborated with home health agencies, used telehealth, or made house calls experienced lower readmission rates related to pneumonia. Case management services and referrals to home health agencies were among the main factors that affected readmission rates.

Evidence-based recommendations to prevent preterm births include assessing patients’ risk levels and considering a variety of potential complications and health problems.