Key Terms
When a patient who was discharged from the hospital winds up going back for the same or related care within 30, 60, or 90 days
What is Hospital Readmission?
This part of the handoff quickly tells the receiver how sick the patient is right now—are they stable, a watcher, or unstable ("I.S.")
What is Illness Severity?
This team member is responsible for documenting the hospitalization and outpatient plan in a record that follows the patient after discharge
Who is Provider/Physician?
This NYC government agency helps older adults find home care, case management, legal services, and home-delivered meals across the city
What is NYC Department for the Aging?
The electronic, privacy-secured database housing all patient-related information in a health system
What is Electronic Medical Record (EMR/EHR)?
This element provides a concise overview of the patient, including why they were admitted, what’s happened so far, and the current plan ("P.S.")
Patient Summary
This healthcare professional reinforces discharge education and often identifies patient confusion
Who is Nurses?
This New York State government–designated protection and advocacy agency supports the rights of people living with disabilities
What is Disability Rights New York?
The standard process of communicating patient information for the purpose of transferring responsibility of their care from one team/person to another
What is Handoff?
This section outlines what still needs to be done, by whom, and by when during the patient’s care ("A.L.")
What is Action List?
This team member initiates discharge planning from the day of admission & connects patients with essential resources
Who is Social Worker?
This NYC nonprofit is one of the oldest in the city and provides legal, housing, education, and elder care services
What is Lenox Hill Neighborhood House?
A standard process to prepare for a patient’s anticipated health care needs after they leave the hospital
What is Discharge Planning?
This component focuses on anticipating potential changes in the patient’s condition and planning how to respond if they occur ("S.A.")
Situation Awareness
These groups support patients outside the hospital with social and functional needs
What is Community Based Organizations?
This NYC nonprofit improves health and well-being for people living with HIV/AIDS, cancer, and other serious illnesses by alleviating hunger and malnutrition through home-delivered meals and nutrition education
What is God’s Love We Deliver?
The movements of patients from one healthcare setting to another including hospitals, primary care practices, long-term care facilities, home health, or rehabilitation facilities.
What is Transitions of Care?
In this final step, the receiver repeats back key information, asks clarifying questions, and confirms next steps ("S")
What is Synthesis by Receiver?
This team focuses on preventing readmissions through follow-up calls and coordination
Who is the Care Management Team?
This nonprofit organization for older adults focuses on reducing social isolation through mental health services, education, and meal delivery
What is DOROT?