If answered question the Specific Action Specific Action(s) Gap Analysis Questions Yes No plan(s) including persons responsible and timeline to complete Transition Comprehensive communication with 3a) Before discharge, schedule follow-up medical providers appointments and post-discharge 3b) For patients without a PCP work with the health plans, Medicaid, etc. to identify and link patient with PCP. 3c) Collaborate with post-acute care and community based providers to improve communication and transition to next level of care. 3d) Send discharge summary and hospital care plan to PCP within 24 to 48 hours of discharge. 3e) Conduct post-discharge follow-up calls within 48 hours of discharge; reinforce components of care plan using teach-back and identify any unmet needs such as access to medication, transportation to follow-up appointments, etc. 4a) 4b) 4c) Plan 4d) Ongo 5a) 5b) 5c) 5d) 5e) 5f)
Specific Action(s) Gap Analysis Questions Yes No If answered question the Specific Action plan(s) including persons responsible and timeline to complete Transition Comprehensive communication with providers 3a) Before discharge, schedule follow-up medical appointments and post-discharge 3b) For patients without a PCP work with the health plans, Medicaid, etc. to identify and link patient with PCP. 3c) Collaborate with post-acute care and community based providers to improve communication and transition to next level of care. 3d) Send discharge summary and hospital care plan to PCP within 24 to 48 hours of discharge. 3e) Conduct post-discharge follow-up calls within 48 hours of discharge; reinforce components of care plan using teach-back and identify any unmet needs such as access to medication, transportation to follow-up appointments, etc. 4a) 4b) 4c) Plan 4d) Ongo 5a) 5b) 5c) 5d) 5e) 5f)