Patient Transitions to Post-Acute Care

It’s estimated that 40% of all Medicare patients go into post-acute care and of those, nearly 23% are readmitted to the hospital within 30 days. This podcast highlights what one organization plans to do to reduce their readmissions.



Heidi Young, RN

Senior Quality Project Manager

ProHealth Care 


Jessica Zuercher, MS, MBA, RN

Director, Continuum of Care

ProHealth Care



Lindsay Mayer, MSN, RN

Senior Director, PI Collaboratives Programs



For more information, email


Show Notes:

[00:45] ProHealth Care has a multidisciplinary all-cause readmission team for post-acute patients

[1:00] ProHealth Care has shifted their focus to look at anywhere along the continuum of care for opportunities to prevent readmissions

[2:52] Earlier efforts to reduce readmissions were ineffective because of lack of follow up

[3:35] ProHealth joined the Vizient Patient Transitions to Post-Acute Care Collaborative

[4:00] They developed plans with facility partners, medial directors and sepsis team, making it collaborative and connected with all parties.

[4:36] Worked as a group to detail how to fully operationalize their preventive strategies

[6:30] Embedded medical directors and Advanced Practice Providers

[7:03] Plans for follow up


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