Transition Basics
This type of transition occurs when a patient is discharged from a hospital to a nursing facility or back home.
What is a care transition?
A care manager should contact the patient or caregiver within this time frame after a hospital discharge.
What is Within 2 business days or before discharge (whichever is sooner)
Ensuring the patient understands this before discharge helps prevent unnecessary hospital visits
This person is the most critical member of the care team.
This federal law ensures patient privacy and governs how health information is shared.
What is HIPPA
This document is essential to review when a patient is discharged and includes medications, follow-up appointments, and discharge instructions.
What is the discharge summary?
This health professional must be notified about the patient's hospitalization and discharge to ensure follow-up care.
These barriers, such as lack of transportation or food insecurity, must be assessed and addressed.
What are social determinants of health?
Engaging this person or people is especially important if the patient has cognitive impairment.
Health Home care management is often funded through this government insurance program
What is Medicaid?
The first 48 hours post-discharge are considered this in terms of risk for hospital readmission.
What is a high-risk period?
A HHCM should ensure these tasks are completed when the patient is ready for discharge.
What are:
•Participate in discharge planning
•Confirm and review with patient medication instructions, follow-up appt, and who to contact post discharge for any concerns
•Confirm or Arrange transportation
This plan outlines warning signs, when to call the doctor, and how to manage chronic conditions.
This approach empowers patients to take an active role in managing their health
This is the process of continuous quality review and improvement in care transitions.
This process ensures all of a patient’s medications are accurate and up to date after discharge.
What is medication reconciliation?
Sharing this document with the provider is important to continuity of care.
This type of patient education, often involving repeat-back methods, helps confirm understanding
Care managers should encourage patients to prepare a list of these before provider visits.
These events require a transition of care action by the HHCM
What are ER visits, Inpatient Stays, Physical Rehabilitation, Detox Facility transitions?
This CMS quality measure tracks hospital readmissions within this number of days post-discharge.
What is 30 days?
A care manager may use this type of consent form to legally coordinate care across multiple providers.
Appointment verification consist of these HHCM responsibilities
What are Confirm follow-up appointments were attended, if missed, re-engage patient and reschedule. If the admission was related to behavioral health, patient requires two appointments within 7 days and 30 days (attendance to both need to be confirmed)
This tool can assess a patient’s readiness to manage care after discharge
A face to face attempt is REQUIRED during and upon discharge within 1 day from this setting.
What is Detox Facility?