MRP
MRP stands for
What is Med reconciliation postdischarge
What is time frame we are to outreach once notified of discharge?
What do we do if we can't reach patient?
What if we can't reach after 3 attempts
Where is this letter found?
What is 24 hours
What is document in a comment
What is send letter
What is under letters on hub, plug in mode under Care Coach (there is no chronic one at this time)
When do we initiate Care Plans for transitional patients?
When do we update them?
What are other times we should update?
What is Initial Inpatient assessment
After d/c and full post d/c assessment completed
When goals are met or needs/ patient status change
We have complex rounds at this current frequency
What is monthly?
These people attend huddle daily
What is entire team
The billing code used to capture or get "credit" for MRP.
Who can do MRP with 1111F codes?
What is 1111F
Pharmacist, RN, NP, MD
What is typical expected touches for transitional once d/c'd? (We will have this structured once using acuity tool)
What is 1-2x/wk and prn
How many Goals and Tasks should transitional patient have at a minimum? How many for patient and how many for CC?
How often should these be reassessed at a minimum along with program enrollment?
What is 2 goals and 2 tasks per each goal
What is any change of status, at each visit as appropriate and also a minimum of every 30 days
This person facilitates the rounds
Who is CA
These topics are discussed by BH
What is any pertinent info gathered day prior or anticipated needs on schedule for today
MRP is done for what reason?
What is QUALITY (to show we are comprehensively caring for our patients post d/c)
We communicate with provider/clinic about this patient enrollment when and how?
What info should be shared at huddle?
What is at huddle and by sending initial assessment inpatient and post d/c assessment.
Basic high level info regarding facility location and event that led to admission or major changes during admit such as more decline, transfer to ICU and cause (do not need to give lab values etc). Transfer to rehab or another facility
4 ways we write our goals are__________
What is co-create with patient, individualized, attainable, short term
This person presents completed round form and describes why patient is being discussed
Who is the CC?
These topics are discussed by Resource SW
What is any pertinent info/outcomes gathered day prior or anticipated needs on schedule for today
MRP impacts what quality measure and how many stars are we "shooting" for?
What is MRP gap and we want to be 5 STARS
We also communicate ongoing with pertinent info/changes as needed by what methods?
TE's, Complex rounds, wkly 1:1's, also would still assign assessment for full details
Who should be able to take care of your patient per your care plan follow in your absence?
What is anyone caring for your patient
The patient list is shared with interdisciplinary team members at least this many days prior
What is 3
These topics are discussed by CC
What is current admits/discharges, anticipated needs, patient on list to see today. Any pertinent info regarding patients discussed above. Give example____
A med rec can be done at this time______ and MRP can be done at this time_______
What is anytime for med rec and 30 days post d/c for MRP
When does the transitional program enrollment begin?
When does the 30 day enrollment get updated?
How do we know what to put in when we enroll for date of d/c if unknown?
What is day of admission
What is day of d/c
What is estimate and then update when known
Plan of Care and Care Plans differ in this way_____
What is Plan of Care is the entire patient plan by Interdisciplinary Team, including all areas such as medications, follow ups, treatments. A Care Plan is made and agreed upon to reach specific goals with assigned tasks pertaining to current problem being coached and managed by CC and patient.
These patient types are presented during rounds
What is patients we are CURRENTLY coaching and can speak on their circumstances with knowledge. Also, patients that are not successful with current plan of care or care plan despite all of our efforts thus far
We prepare for huddle by _______
What is research on current admits/discharges, having daily schedule updated to share which patients we are seeing for the day