the ED or 2359 Observation Unit Hospital Care Summary electronicfaxed SNF andor PC HospitalED Schedule Patient Appointment see triage if discharge to home Reinforce Discharge Plan ID: 477969
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Slide1
Patient Receives Care in
the ED or 23/59 Observation Unit
Hospital Care Summary
(electronic/faxed SNF and/or PC)
Hospital/ED
Schedule Patient
Appointment
(see triage)
(if
discharge to
home)
Reinforce Discharge Plan
Including Medication Reconciliation
Patient
Education
Provider Feedback to Hospital
SMOOTH COMMUNICATIONS
OVERVIEW
Cohesive
plan of care between transitions
at
arrival and discharge from the
hospital
(
Stay of
less than
24 hours
)
DRAFT
Community
/ Provider
Forum to Discuss Effectiveness
Role of
Primary
Care (PC) Provider or SNF
Role of Hospital/ED
What happens prior to hospital care?What happens during hospitalization? What happens at discharge?What happens post discharge?
1
1
3
4
4
2
Follow up by
PC
Ensure Appointment
(see triage)
3
4Slide2
Patient Receives Care in Hospital
PC Notified of
Admission
Discharge Plan
(electronic/faxed SNF and/or PC)
Hospital Follow Up Call to Patient
Hospital Schedule Patient
Appointment
(see triage)
(
if
discharge to
home)
Reinforce Discharge
Plan
and Medication
Reconciliation
Patient and Care Giver Education
Provider Feedback to Hospital
Patient and
Care
Giver Communication
Specifics on
Discharge Plan including Medications
Education
SMOOTH COMMUNICATIONS
OVERVIEW
Cohesive
plan of care between transitions
at
arrival and discharge from the
hospital
(
Stays
more than
24 hours
)
DRAFT
Community
/ Provider
Forum to Discuss
Effectiveness
Role of
Primary
Care (PC)
and SNF
Role of Hospital
What happens
prior to
hospital care?
What happens
during
hospitalization?
What happens
at
discharge?
What happens
post
discharge?
1
2
3
3
3
4
4
4
3
Follow up by
PC
Ensure Appointment
(see triage)
1
2
2
4Slide3
Smooth Communications – Transitions in Care
Discussion Questions
What happens when the patient does not have a primary care provider?
Do we need a separate flow diagram and agreed upon expectations for who does what and
when in this situation which is fairly common?How will this change the expectations regarding appointments and the timing of follow-up?
Do we need specific, agreed-upon criteria that will guide the clinical triage of patients at the time of discharge? Or, is it okay to leave this to the clinical judgment of the discharging provider?What strategies are likely to be most effective in
building accountability and responsiveness
among community physicians for their proactive participation in the patient hand-off’s?
What are the barriers for community physicians and how can we overcome them most effectively? What do community physicians need to be most effective?Are hospitals/emergency departments organized and resourced in the most effective way to effectively facilitate the hand-off’s and provide information?
What do hospitals/emergency departments need to be most effective?