Transitional Care/AllThrive365 Info
ACTIVATE's goal
Reduce readmission rates
What disqualifies patients from being eligible for Transitional Care Program services?
Live out of Maricopa (can still receive DME if hospitalized within 90 days), under 18 years old, d/c to inpatient facility (can reach out after dc if they still need help)
Patient needs help navigating their healthcare, what available options/resources are there to assist?
Gellert Health, Pathways to Wellness, Pathways to Healthier Living, PCAs
Angela's happy place
Any place warm - Florida, Hawaii, beach
Erica is ____ handed
Left
CATCH's goal
Reduce ED utilization
What reports should be run weekly?
Enrollments, Home Visits, Pending Documentation, Open Referral Statuses
What chronic health conditions should we provide patient education for?
Diabetes, CHF, sepsis
Rollerskating
Where was Celiana born?
England
How many locations do we cover for Transitional Care services and what are they?
7 - IMC, CRMC, MGMC, AZG Mesa, AZG Laveen, Westgate, SJH
What information should be included in a Transitional Care Note?
Who you spoke to/who was there for the conversation, details about the conversation, any information/resources provided, any future follow up information needed
CHF red zone symptoms and next steps
Hard time breathing, struggling to breathe, Chest discomfort/pain, Feeling faint, Feeling confused or can’t think clearly. Go to ER.
Sarah participated in this sport in Middle School
BMX riding
Rocio played these sports in high school
AllThrive365's Values
Compassion, Growth, Resilience, Openness
What should you do if you lose your receipt for a purchase made with your PCard?
Tell PM, complete missing receipt form
What is the difference between SSI and SSA?
The Social Security Administration (SSA) is a federal agency that administers various social security programs, including Supplemental Security Income (SSI). SSI is a needs-based program that provides financial assistance to low-income individuals, especially those who are disabled or elderly
How many referrals did Transitional Care Programs get in May 2025?
264
Catie's favorite ice cream flavor
Strawberry
11 - Adult Foster Care, Behavioral Health Homes,
Food Programs, Health Education, Transitional Care, Housing Programs:Casa Del Sol, Affordable Housing, Home Improvements, Adult Day Health Centers, Community Resource Centers, Resource Navigator
What date should documentation for the previous month be entered by and why?
6th of every month for MOR reports
Advance directives are legal documents that allow individuals to make decisions about their medical care in advance, ensuring their wishes are honored if they become unable to communicate. Includes Medical Power of Attorney, Mental Health Care Power of Attorney, Living Will, DNR, POLST (Physician Orders for Life-Sustaining Treatment, portable medical order that helps individuals with serious illnesses or frailty communicate their treatment preferences in the event of a medical emergency), General or Financial Power of Attorney.
Very important that copies of all Health Care Advanced Directives be given to the patient’s agents, medical providers, and any other people that they want to have their wishes known
What is Transitional Care Programs' most commonly referred resource?
Kindness Closet