1. Transitional Care Post Discharge; Tracking and Documentation

2. Objectives Discuss the systems for tracking and managing patients transitioning from the hospital, Describe critical transitional interventions that prevent readmission and use case studies to exemplify transitional care.

3. Highest risk patients… Highest risk patients (starting with highest level) – Seen in the emergency room – Admitted/discharged from the hospital – Assessed in the office as highest risk Top 5% of the panel - “highest” of the high risk patients 3

4. System of tracking and documenting transition care List of patients admitted/discharged from the hospital with demographics, admitting diagnosis, discharge plan Discharge date and date of the transition call/s Medication reconciliation Safety assessments (support, activity, pain management, nutrition, cognition) Assessment of the driver (causative factor) Ongoing: CM interventions, assessments, changes to the plan of care, and next scheduled interaction 4

5. Discharge Plan Contact the pt. within 24-48hrs post discharge High risk patient, review discharge plan with inpatient Case Manager Verify that all orders are in place ie Home Health, DME etc Post discharge appointment 5-7 days.

6. Medication Reconciliation What medications was the pt. on prior to hospitalization ? Ask the patient to read you their medications. Review discharge medications. If concerns contact retail pharmacy. Review medications during home health visit. Have patient bring medications to appt.

7. Safety assessment Support Activity Pain Management Nutrition Cognition 7

8. 8 Assessment of the driver (causative factor) related to hospitalization

9. Other priority assessments (Use Intake Assessment Tool) 9

10. Identify patient problems (Use Care Plan Tool) 10

11. Plan of Care Next follow up What needs to be put in place to keep the patient safe? What does the patient agree to? Goals ?

12. Next scheduled interaction PCP appointment 5-7 days post discharge Meet with patient at PCP appointment Call patient once a week for 4 weeks (4 touches) Notify Home Health that patient has a CM Post 30 day TOC assess if patient has ongoing needs. 12

13. CM Interventions Coordination of care with the Medical Neighborhood ie Home Health,DME,Pharmacy,Community Services Ongoing reinforcement of the discharge plan Follow-uo appointments Education ie HF,COPD,DM Medication Adherence

14. Questions? 14