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New patient care model reduces hospital re-admission rates

A CHRP-funded demonstration project aimed at improving patient care for people with HIV and AIDS has reduced the number of hospital re-admissions at one Bay Area hospital by 44 percent.

The new approach — jointly funded by the California HIV/AIDS Research Program (CHRP) at the University of California, the Alameda County Health Care Services Agency, the Gordon and Betty Moore Foundation and Alameda Health System  — puts primary care physicians at the helm of an integrated care team that includes social workers, psychologists and medical specialists.

These collaborative teams form virtual “patient-centered medical homes” that work together to ensure that patients come to appointments, take their medications and get the care they need.

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