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Transition of Care

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Transition of Care

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Fill-in the blanks to complete the Transition of Care workflow process.

Created by

Sonia R Lundy
Sonia R Lundy
United States

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Transition of Care
 

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Transition of CareOnline version

Fill-in the blanks to complete the Transition of Care workflow process.

by Sonia R Lundy
1

Member progression Due SharePoint change 5 notification 1 date TruCare significant reason Note reason 3 needs 3 admitting 3 disease ICT post PGA update attempts

Upon receipt of the Assessment Hospitalized task , the Complete Care manager will outreach the admitting facility discharge planner within business days . To document the outreach , the care manager will select as the for contact . The care manager will document a summary of the discussion in an Interdisciplinary Team ( ICT ) . The discussion summary must include the name of the person speaking with the care manager , contact number , details of any discharge , and potential discharge .

The discharge planner confirms discharge is scheduled for Monday , 3 / 15 / 2021 . The care manager must contact the member within days - discharge . Care managers are aware they must initiate a total of outreach within business days post - discharge . On Thursday , 3 / 18 / 21 , the care manager made successful contact with the member .

The care manager must the care plan to include at minimum PGA specific to Transition of Care / ER , document the conversation and care plan toward goals in the care plan note , and educate the member on management and red flags .

To meet the minimum Quality Assurance , the care manager must ensure the care plan note states the for admission , ONE Transition of Care must relate to the diagnosis in a SMART Goal format , and the PGAs in must match the PGAs in .

The care manager must remember to complete and document if the member was assessed for a in condition .

 
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