worsening condition and for each week that patients being consumers 2 days after discharge to one telephone or response strategies visit is not discharged from the conduct a secondary assessment and face‐to‐face Making three follow hospital to home (the intervene on identified needs, scheduled contact per month ► up phone calls focused on Is on call seven days per Universal Checklist) including understanding discharge Coordinate care ► ► reviewing the progress week for home visits and General instructions, transportation issues, from all providers ► toward established goals, Assessment of telephone access physician follow‐up, burdened Collaborate ► reinforcing the Provides active Preparedness (GAP), a caregivers, problems with home with hospital ► importance of engagement of patients and component list of health care, difficulty obtaining discharge planners maintaining PHR, and issues important to family caregivers with and/or understanding medications. and make a home supporting the focus on goals providers and patients visit after any Follow‐up: The BCC follows up patient’s self-management Provides communication (and their caregivers) hospitalization with consumers at 30 days ► surrounding the to, between, and among the to track their progress patient, family caregivers, readiness of patients and address needs and health care providers. for transition out of hospital
worsening condition and response strategies ► Making three follow up phone calls focused on reviewing the progress toward established goals, reinforcing the importance of maintaining PHR, and supporting the patient’s self-management for each week that visit is not scheduled ► Is on call seven days per week for home visits and telephone access ► Provides active engagement of patients and family caregivers with focus on goals ► Provides communication to, between, and among the patient, family caregivers, and health care providers. patients being discharged from the hospital to home (the Universal Checklist) ► General Assessment of Preparedness (GAP), a component list of issues important to providers and patients (and their caregivers) surrounding the readiness of patients for transition out of hospital consumers 2 days after discharge to conduct a secondary assessment and intervene on identified needs, including understanding discharge instructions, transportation issues, physician follow‐up, burdened caregivers, problems with home health care, difficulty obtaining and/or understanding medications. Follow‐up: The BCC follows up with consumers at 30 days to track their progress and address needs one telephone or face‐to‐face contact per month ► Coordinate care from all providers ► Collaborate with hospital discharge planners and make a home visit after any hospitalization
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