The post discharge tool was created to aid the patients and families take action to keep the patient's recovery on the track. The tool's main focus is to keep patients out of the hospital. On e way to do this is to make sure patients follow their care plan.
10 key components of post discharge model are given below:
.Assure that there is close and trusted interaction between the outpatient care team and the hospital discharge planners
Begin the patient-interaction portion of the program with a post-discharge in-home assessment
Once the in-home assessment has been conducted, the nurse practitioner and social worker should meet with the primary care physician to develop a pro-active care management plan that is consistent with the participant's goals.
Conduct weekly interdisciplinary team conferences
Provide specialized care and considerations for common geriatric conditions
Consider the unique physical and psychosocial needs of low-income seniors including dual eligibles
focus not only on treating a person's medical condition but for managing a broad array of care needs across multiple settings
Ensure that your program includes a focus on patient education
Have the information technology infrastructure in place
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