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Reducing Hospital Re-admissions (Inpatient (Physician (-Begin discharge…
Reducing Hospital Re-admissions
Inpatient
Physician
-Begin discharge planning upon admission
-Order appropriate consults ASAP
-Identify high risk patients early (high risk for re-admission) and plan on ordering appropriate services upon discharge
-Establish outpatient followup (primary care etc)
Nursing
-Discharge Summary review
-learning assessment
-Begin discharge planning upon admission
-Collaborate with attending, pharmacy, as well as other specialties in discharge planning and needs.
-Assess patient understanding
Pharmacy
-Reconcile home medications
-Collaborate with attending MD re: dated medications, contraindications, medication noncompliance etc
-Collaborate with nursing re: medication teaching
Therapies
-PT
-OT
-Assess ADL needs
-Help patient improve strength
-Assist patient develop safety practices
Dietician
-Assess nutrition needs
-Collaborate with interdisciplinary care team regarding nutrition needs
Primary Care
-Follow up with patient after discharge
-Collaborate with home care to modify care plan where appropriate
-Provide medication upon discharge
Home care
-Execute discharge summary
-Collaborate with inpatient care team in facilitating discharge
-Implement discharge orders and ensure clarifications are made.
-Continue patient teaching and facilitate patient compliance
-Maintain a safe home environment
Case Management
-Assess needs for services necessary upon discharge
-Collaborate with interdisciplinary care team
Social Services
-Assess welfare needs
-Assess support system and other patient concerns
-Collaborate with interdisciplinary care team
Pharmacy
-Pt teaching
-Collaborate with home care and primary care with medication management