Written by: Center for Care Innovations

The Challenge

Reduce preventable readmissions and improving post-discharge care for patient-centered medical home patients. This case study looks at the innovation design process and implementation of an email notification system for care managers at Olive View-UCLA Medical Center, as part of CCI’s Safety Net Innovation Challenge program, funded Blue Shield of California Foundation.

“The PCMH can only help patients navigate post- discharge care if they know about discharged patients,” said Mark Richman, Physician Innovator at OVMC.


An automated email notification from the hospital alerts the PCMH care manager that a PCMH patient is currently in OVMC’s ED or has been admitted to OVMC. Another email alerts the care manager when the patient is discharged from the ED or IP setting and includes the discharge summary. OVMC is testing this approach in a randomized, controlled trial, with patients randomly assigned to a group receiving the experimental intervention or a control group receiving standard procedures.

Anticipated Impacts

Prioritized patient access to primary care after ED use or IP admission; more effective discharge planning, resulting in decreased length of stay; increased patient satisfaction; fewer hospital readmissions; cost savings.

Download the case study below.

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