Background: The Palo Alto VA Hospital has an interdisciplinary Clinical Command Center (C3) that includes “Flow” nurse practitioners (NPs) who work closely with case management, social work and primary medical teams to identify and address barriers to care and assist in discharge planning and coordination. We have created a novel collaboration between a C3 Flow [...]

Background: Case Managers (CM) are now a standard presence in emergency departments (ED) of large hospitals, partnering with ED and Hospital Medicine providers to improve care. They are integral in improving hospital throughput and reducing unnecessary hospital admissions and readmissions. Case Managers generally identify high-risk patients using a manual chart review process or by provider [...]