- Educate the patient about his or her diagnosis throughout the hospital stay
- Make appointments for clinician follow-up and post-discharge testing
- Discuss with the patient any tests or studies that have been completed in the hospital and discuss who will be responsible for following up on results
- Organize post-discharge services
- Confirm the medication plan
- Reconcile the discharge plan with national guidelines and critical pathways
- Review the appropriate steps for what to do if a problem arises
- Expedite transmission of the discharge summary to the providers accepting responsibility for the patientās care after discharge
- Assess the patientsā degree of understanding by asking them to explain in their own words the details of the plan
- Give the patient a written discharge plan at the time of discharge
- Provide telephone reinforcement of the discharge plan and problem-solving two-three days after discharge
Project RED does not rely on hospitalist participation as much as project BOOST. A discharge educator (DE) is in charge of educating and advocating for the patient. However, physicians are expected to coordinate with the DE and provide information, such as potential barriers to discharge. Physicians who can help identify patients who would benefit from RED intervention and are open to communicate with the DE will guarantee success of the program. Transitional Care Model and Care Transitions Intervention The Transitional Care Model (TCM) is designed for older adults with certain risk factors, including history of recent hospitalizations, multiple chronic conditions or medications, and poor ratings of self-health. Patients that meet the criteria are assigned a transitional care nurse (TCN) who works with the patient and medical team to coordinate patient care. When hospital inpatients are enrolled in the TCM program, the TCN conducts an assessment and defines the patientās needs and required services. The TCN then collaborates with the physicians and other care team members to create a care plan. The TCN continues to work with the patient after discharge and will accompany patients on follow-up appointments with primary care physicians or specialists. Similarly, the Care Transitions Intervention (CTI) is a four-week program for patients with complex care needs. A care transitions coach, typically an advanced practice nurse (APN), works with patients who are identified as requiring assistance meeting the goals of the four coaching pillars:
- Medication self-management
- Dynamic personal health record
- Timely physician follow-up
- Promotion of patient understanding of āRed Flags” and how to respond
Hospitals have successfully used the CTI model to improve transitions from acute care hospital to home and reduce unnecessary emergency department visits. Some facilities have also made intervention from the care transitions coach the standard of care for patients with select conditions (e.g., dementia, congestive heart failure, chronic obstructive (CHF), pulmonary disease (COPD)). Locum tenens physicians and NPs must be prepared to collaborate with these patient advocates when treating patients that require special assistance. Although physicians or NPs may not currently encounter these initiatives on their assignments, readmission reduction strategies will become more common as hospital payments continue to be affected by readmission rates.