#57 The federal government invested $500 million to understand why seniors are readmitted to the hospital within 30 days—and uncovered six key “preventable” gaps driving the problem. Ethan Guerrieri, VP of Operations at Preferred Care at Home, breaks down the research, explains each gap, and shares how his team turned these insights into their Smooth Transition Care Program. Designed for hospitals and SNFs, this evidence-based approach equips case managers and discharge planners with the tools and education they need to reduce readmissions—and shows why home care is the missing link in keeping clients safely at home.

• Ethan Guerrieri
• Preferred Care at Home
• Smooth Transition Care BROCHURE
• Smooth Transition Care FLYER
• Smooth Transition Care PERSONAL HEALTH RECORD

Sponsors:

• GUIDE-Ready Respite Provider Program (Debbie Miller + Harmonic Health)
• CMS GUIDE Participant List (spreadsheet download)