TOC Routing
For an unassigned CSP member identified through inpatient census/ADT, this staff role creates the EOC and referral to TS.
Who is the TOC RN?
These two assessments are completed on all discharges.
What are Post Discharge TOC Assessment and OK Transitions of Care?
A green discharge flag generally means this...
What is required contact and assessment work is met?
A BH discharge requires member contact within this many days.
What is 3 days?
PNCMA identifies a need for a level two pediatric member. This is the next planning tool.
What is an IMP?
A member is admitted 48 hours or less, including observation. The workflow routes to this team as applicable.
What is the Care Navigator team?
Medication review includes current medications, adherence, understanding, barriers and this possible medication concern.
What are adverse effects/missed doses/follow-up need?
A yellow discharge flag at two days means this...
What is required work is missing?
A new home placement requires TOC assessment within this many days of notification.
What is 5 days?
PCMA findings should include barriers in this domain, such as transportation and food insecurity.
What are SDOH needs?
An assigned member is admitted for 2-14 days. This worklist action item is created at high priority.
What is Transition of Care Outreach?
This document should be reviewed at discharge to confirm plan and follow-up.
What is the discharge summary?
A red discharge flag at seven days means this.
What is required work remains unfinished?
A newly assigned CN/CN must make telephonic or face to face contact within this many days.
What is 5 days?
A 17.5 year old lacks ID and stable housing. This assessment and plan update are indicated.
What are a2A assessment and IMP update/referrals?
At discharge, this high-priority action is created.
What is Outreach for Transition of Care?
Three calls must be initiated within this timeframe for the TOC workflow described.
What is 10 calendar days?
This primary dashboard tab is used to manage inpatient stay work.
What is the inpatient tab?
When a youth turns 18, this care planning workflow supports adult transition.
What is a2A?
A new foster household reports medication confusion after discharge. Name two immediate workflow areas to address.
What are medication review and TOC/IMP follow-up?
Name the unique population group requiring intensified workflow review.
What are admissions greater than 15 days, out of state admissions, or organ transplantation?
If the member cannot be reached after required outreach, staff should follow this process.
What is the UTR process?
A member has a red discharge flag and complex needs. Name the first step.
What is verify missing outreach/assessment/documentation and act promptly?
An inpatient to inpatient transfer requires outreach plus updates to these plan items.
What are the IMP and target dates?
A red dashboard flag, missed assessment, and unaddressed barrier all point to one care responsibility.
What is timely action and complete documentation?