Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, Schwartz JS. Transitional care of older adults hospitalized with heart failure: A randomized, controlled trial. Journal of the American Geriatrics Society. May 2004;52(5):675-684. Project BOOST: Better Outcomes for Older Adults Through Safe Transitions Tool for – Identification of High-Risk Patients. Available at (search risk assessment tool). van Walraven C, Dhalla IA, Bell C, Etchells E, Stiell IG, Zarnke K, Austin PC, Forster AJ. Derivation and validation of an index to predict early death or unplanned readmission after discharge from hospital to the community. Canadian Medical Association Journal. 2010; DOI: 10.1503/cmaj.091117. 1D. Create a customized discharge plan based on the assessment. A customized and structured discharge plan based on patient needs readmission rates “reduces for older people admitted to the hospital with a medical condition.” On the day of admission, initiate a customized plan of care based on the level of care indicated by the standardized admission assessment. In for National its 2003 report, “Priority Areas the Institute of Medicine (IOM) recommended that providers communicate and reinforce Action,” and central role in managing their illness., The person designated to be patients’ active accountable for the effective discharge of the patient (e.g., the primary nurse, a case patient’s manager, a discharge planner, a discharge coach, or a hospitalist) should initiate the patient’s plan of care based on the enhanced assessment. A customized discharge planning process includes the elements listed below. Assess and predict discharge basic needs and incorporate them into the patient’s discharge plan. Communicate with agencies early if referrals for home health care, skilled nursing, an advanced practice nurse, or a transitions coach are under consideration., Discuss preparations for discharge in daily and multidisciplinary rounds. Re-evaluate the estimated discharge date daily and adjust the plan. Standardize the discussion of preparation for rounds or bedside report. Daily goals should include progress toward going home. Questions to address include: Where will the patient likely go after discharge?
Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, Schwartz JS. Transitional care of older adults hospitalized with heart failure: A randomized, controlled trial. Journal of the American Geriatrics Society. May 2004;52(5):675-684. Project BOOST: Better Outcomes for Older Adults Through Safe Transitions – Tool for Identification of High-Risk Patients. Available at (search risk assessment tool). van Walraven C, Dhalla IA, Bell C, Etchells E, Stiell IG, Zarnke K, Austin PC, Forster AJ. Derivation and validation of an index to predict early death or unplanned readmission after discharge from hospital to the community. Canadian Medical Association Journal. 2010; DOI: 10.1503/cmaj.091117. 1D. Create a customized discharge plan based on the assessment. A customized and structured discharge plan based on patient needs “reduces readmission rates for older people admitted to the hospital with a medical condition.” On the day of admission, initiate a customized plan of care based on the level of care indicated by the standardized admission assessment. In its 2003 report, “Priority Areas for National Action,” the Institute of Medicine (IOM) recommended that providers communicate and reinforce patients’ active and central role in managing their illness., The person designated to be accountable for the effective discharge of the patient (e.g., the patient’s primary nurse, a case manager, a discharge planner, a discharge coach, or a hospitalist) should initiate the patient’s plan of care based on the enhanced assessment. A customized discharge planning process includes the elements listed below. Assess and predict discharge basic needs and incorporate them into the patient’s discharge plan. Communicate with agencies early if referrals for home health care, skilled nursing, an advanced practice nurse, or a transitions coach are under consideration., Discuss preparations for discharge in daily and multidisciplinary rounds. Re-evaluate the estimated discharge date daily and adjust the plan. Standardize the discussion of preparation for rounds or bedside report. Daily goals should include progress toward going home. Questions to address include: Where will the patient likely go after discharge?
5%20-%20How-to-Guide%20Patient%20Assessment-Readmissions%20pgs%2016-21%20-%20Key%20Change%201.docx