Patient Interventions Tracking Tool: Inpatient Patient Name: ______________________________________ Medical Record Number: ______________________________ Date of Admission: ___________________________________ Interventions - Inpatient Completed? Initials Yes - Date: No N/A Prior authorization obtained for any (e.g., not on meds; medication(s) for which it is required / / prior auth not required) Medication fill at discharge Yes - Date: No N/A (Patient discharged with full supply of all (e.g., not on meds; medical & psychotropic meds in hand for the / / residence supplies) period clinically indicated) Warm Hand-off to receiving provider Yes - Date: No (during inpatient stay or on day of discharge; / / may include outpatient therapist, psychiatrist, health home, care/case manager, peer, etc.) Discharge plan includes a high-intensity step-down program and/or community-based Yes No care coordination follow-up (e.g., Partial hospitalization program, health home, intensive case management, assertive community treatment (ACT), mobile crisis, visiting nurse, peer bridger) Intervention Post-Discharge – Date of Exclude transfers to other inpatient settings Discharge: / / and discharges to State Psychiatric Centers Follow-up phone call to client/family/ Yes Date of Call: – caregiver within 72 hours of discharge No / / (include only calls comprising the 4 red components of Project calls: assess Completed by clinical status, review medications, hospital/inpatient staff review/reinforce outpatient appointments, Verified completion by trouble-shoot any barriers) community partner 30-Day Outcomes Date of None First outpatient BH follow-up session OR First Session: within 30 days (exclude and greet” in warm hand-off) “meet / / 30-day readmission to this hospital (confirmed in Electronic Medical Record 30+ days post d/c; exclude planned rehab Psych SUD Medical None admission after detox d/c) Revised 6/22/15
Patient Interventions Tracking Tool: Inpatient Patient Name: ______________________________________ Medical Record Number: ______________________________ Date of Admission: ___________________________________ Interventions - Inpatient Completed? Initials Prior authorization obtained for any medication(s) for which it is required Yes - Date: / / No N/A (e.g., not on meds; prior auth not required) Medication fill at discharge (Patient discharged with full supply of all medical & psychotropic meds in hand for the period clinically indicated) Yes - Date: / / No N/A (e.g., not on meds; residence supplies) Warm Hand-off to receiving provider (during inpatient stay or on day of discharge; may include outpatient therapist, psychiatrist, health home, care/case manager, peer, etc.) Yes - Date: / / No Discharge plan includes a high-intensity step-down program and/or community-based care coordination follow-up (e.g., Partial hospitalization program, health home, intensive case management, assertive community treatment (ACT), mobile crisis, visiting nurse, peer bridger) Yes No Intervention – Post-Discharge Exclude transfers to other inpatient settings and discharges to State Psychiatric Centers Date of Discharge: / / Follow-up phone call to client/family/ caregiver within 72 hours of discharge (include only calls comprising the 4 components of Project red calls: assess clinical status, review medications, review/reinforce outpatient appointments, trouble-shoot any barriers) Yes – Date of Call: / / No Completed by hospital/inpatient staff Verified completion by community partner 30-Day Outcomes First outpatient BH follow-up session (exclude “meet and greet” in warm hand-off) Date of First Session: / / OR None within 30 days 30-day readmission to this hospital (confirmed in Electronic Medical Record 30+ days post d/c; exclude planned rehab admission after detox d/c) Psych SUD Medical None Revised 6/22/15
readmissions-pi-tt-inpatient.docx