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