When You Have a New Patient, Don’t Reinvent the Wheel.

Hospital case managers should create alliances with primary care providers who can share information that will help in creating a discharge plan, according to the chief executive officer of El Rio Community Health Center in Tucson, AZ. El Rio has developed a patient portal through which the health center staff and staff at three health systems share information to help patients get the care they need and create smooth transitions. Information on patients' behavioral health issues is also on the patient portal so clinicians at all levels of care will be aware of potential roadblocks to care. The health center staff has regular meetings with skilled nursing facilities and home health agencies, and the next step is to include hospital case managers to work on ways to smooth transitions between all levels of care.