Making moves
Where do I go from here?
Team work makes the dream work
100

It's the standard process in which patient information is communicated between clinicians.

What is a handoff?

100

This service offers nursing, personal care, and medication assistance after discharge.

What is home health?

100

This group calls and ensures the patient follows up to prevent readmissions.

What is the care management team?
200

It's when a patient is moved from one care setting to another.

What is a transition of care?

200

It may be physical, occupational, or cognitive.

What is therapy?

200

They begin discharge planning as soon as the patient is admitted.

Who are social workers?

300

It describes how patients are monitored and supported after they leave the hospital.

What is discharge follow-up?

300

They provide comfort and end-of-life services.

What is palliative and hospice care?

300

They play a big role in patient education.

Who are nurses?

400

It is the process to prepare a patient for their anticipated health care needs after they leave the hospital.

What is discharge planning?

400

It includes outpatient mental health therapy, case management, and peer counseling.

What is behavior health?

400

These supplement the needs of patients without traditional support systems. 

What are community-based organizations?

500

These are transitions of care that are often used to evaluate the quality of care.

What are hospital readmissions?

500

They are appointments when the patient is no longer staying in the hospital. 

What are outpatient visits?

500
They write the discharge summary.

Who are providers?