Emergency CARE Treatment Clinical CCC Level of care department MANAGEMENT plan exists for summaries engaged in utilization Observation all pts obtained for all pre-admission improved Pre-admission Hospitalization high-risk pts triage Clinical Local 30-day Clinical admitted medication CCC readmissions summary pharmacy reconciliation CCC conducts engaged in & ED Triage Rehabilitation by nursing case review for care planning frequency Admission Nursing home staff high-risk pts during reduced Care plan during care admission Discharge Medication Medication instructions Clinical Pts & safety reconciliation given to pharmacist providers outcomes Case review pt/caregiver engaged in engaged in improved Shared medication shared Clinical decisions reconciliation decision summary Discharge making provided to pt CCC reviews planning discharge care CCC actively Care plan Local care plans with engaged in coordinator Instructions pts discharge manages Clinical care planning transfers to summary for high-risk nursing pts home/rehab Clinical summary shared with next provider &/or PCP Community TRANSITIONS Local care CCC engages CCC calls & Population setting OF CARE coordinator patient in visits high-risk health Home (ToC) reviews care patients outcomes Assisted clinical planning; improvement CCC calls, visits F/U calls for living summary & assesses health care plan Pts engaged high-risk patients Domiciliary instructions literacy monitoring; in Medication prior to Rest home CCCs calls encourages management monitoring discharge Home health pts to Care plan Hospice Local care monitor management monitoring Retail coordinator medication, care through Health literacy & pharmacy provides plan compliance motivational education education as interviewing & Medications CCC discusses appropriate use of Life style life style community Local care changes changes services Screenings coordinator CCC conducts Retail Immunizations encourages courtesy calls pharmacist home Pt engagement; pt for high-risk engaged in monitoring; self-management pts, reviews medication educates pt on
Emergency department Observation Hospitalization Clinical pharmacy Rehabilitation Nursing home CARE MANAGEMENT Pre-admission Clinical summary Triage Admission Care plan Medication reconciliation Case review Shared decisions Discharge planning Care plan Instructions Clinical summary Treatment plan exists for all pts Local medication reconciliation by nursing staff Discharge instructions given to pt/caregiver Clinical summary provided to pt Local care coordinator manages transfers to nursing home/rehab Clinical summary shared with next provider &/or PCP Clinical summaries obtained for all high-risk pts admitted CCC conducts case review for high-risk pts during care Clinical pharmacist engaged in medication reconciliation CCC reviews discharge care plans with pts CCC engaged in pre-admission triage CCC engaged in care planning during admission Pts & providers engaged in shared decision making CCC actively engaged in discharge care planning for high-risk pts Level of care utilization improved 30-day readmissions & ED frequency reduced Medication safety outcomes improved Community setting Home Assisted living Domiciliary Rest home Home health Hospice Retail pharmacy TRANSITIONS OF CARE (ToC) CCC calls, visits high-risk patients Medication monitoring Care plan monitoring Health literacy & education Medications Life style changes Screenings Immunizations Pt engagement; pt self-management Local care coordinator reviews clinical summary & instructions prior to discharge Local care coordinator provides education as appropriate Local care coordinator conducts courtesy calls for high-risk pts, reviews CCC engages patient in care planning; assesses health literacy CCCs calls pts to monitor medication, care plan compliance CCC discusses life style changes CCC encourages home monitoring; educates pt on CCC calls & visits high-risk patients F/U calls for care plan monitoring; encourages through motivational interviewing & use of community services Retail pharmacist engaged in medication management Population health outcomes improvement Pts engaged in management
1-CCC-Maturity-Assessment-Template.docx