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CHF: Hospital to Home (Handoff to Post-Hospital Providers: This is to…
CHF: Hospital to Home
Handoff to Post-Hospital Providers: This is to include patients PCP, home-care registered nurses and other providers the patients sees, providing continuity of care between the interdisciplinary teams.
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Assessment: to be done early after hospital admission. Makes understanding what discharge planning needs to be started from time of admission. Evaluates leading causes contributing to readmission.
Early Follow-Up Visit After Discharge: return appointments to be made before discharge. Appointment will typically be within a week of discharge.
Medication Reconciliation: to be done at admission and before discharge. Note any new, discontinued, or changed prescriptions. Patient and/or caregiver must have an understanding on the medication regimen.
Caregiver: Identify who will be included in the care plan i.e. family, friends, and/or hired caregivers. Having a positive and involved support system, as well as patient involvement in care planning, promotes better ability to manage symptoms and follow the care plan.
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Transition in Care: Congestive Heart Failure Readmission to Discharge By, Janice Lavy
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