Client Interventions Tracking Tool: Outpatient Client Name: _______________________________________ Medical Record Number: ______________________________ Date of Hospital Discharge: ____________________________ First post-discharge outpatient appointment that the client is expected to attend from the community: Scheduled date of appointment: _____________________ Actual date of appointment: _________________________ Staff Interventions - Outpatient Initials provided during inpatient stay or at time of Warm Hand-off discharge Yes Date: / / No – (May be conducted by any member of your program’s staff who will continue to follow the client in the community - e.g., therapist, psychiatrist, care/case manager, etc.) Telephone or face-to-face reminder within 24 hours prior to the first post-discharge appointment that the client attended from the Yes Date: / / No – community. (Reminder before the first appointment that the client attends from the community. If the first appointment is a warm hand-off on day of discharge, the reminder calls are expected prior to the next appointment.) Staff 30-Day Outcomes Initials None First outpatient BH follow-up session OR Date of First Session: within 30 days (exclude and greet” warm hand-off) “meet / / any 30-day readmission to hospital Psych SUD Medical None (exclude planned rehab admission after detox d/c) Revised 6/22/15
Client Interventions Tracking Tool: Outpatient Client Name: _______________________________________ Medical Record Number: ______________________________ Date of Hospital Discharge: ____________________________ First post-discharge outpatient appointment that the client is expected to attend from the community: Scheduled date of appointment: _____________________ Actual date of appointment: _________________________ Interventions - Outpatient Staff Initials Warm Hand-off provided during inpatient stay or at time of discharge (May be conducted by any member of your program’s staff who will continue to follow the client in the community - e.g., therapist, psychiatrist, care/case manager, etc.) Yes – Date: / / No Telephone or face-to-face reminder within 24 hours prior to the first post-discharge appointment that the client attended from the community. (Reminder before the first appointment that the client attends from the community. If the first appointment is a warm hand-off on day of discharge, the reminder calls are expected prior to the next appointment.) Yes – Date: / / No 30-Day Outcomes Staff Initials First outpatient BH follow-up session (exclude “meet and greet” warm hand-off) Date of First Session: / / OR None within 30 days 30-day readmission to any hospital (exclude planned rehab admission after detox d/c) Psych SUD Medical None Revised 6/22/15
readmissions-pi-tt-outpatient.docx