Transitions in Long Term Care: The role of a hospital/SNF partnership in assuring effective transitions of care. Aubrey L. Knight, M.D. Chief, Geriatric and Palliative Medicine Carilion Clinic Roanoke, VA. Disclosure.
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Aubrey L. Knight, M.D.
Chief, Geriatric and Palliative Medicine
“Care Transitions: The Hazards of Going In and Coming Out of the Hospital”-
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SNF partnership in assuring effective transitions of care
Skilled Nursing Facility
Ambulatory Care Clinic
Home Health and Hospice
Educate the patient Improvement
Discuss tests and results
Organize post-discharge services
Confirm the medication plan
Reconcile the discharge plan
Review process when problems arise
Expedite the transmission of the discharge summary
Assess patient understanding
Give patient a written discharge plan
Telephone reinforcement in 2-3 days post-dischargeProject RED
Coleman et al. Arch Intern Med. 2006; 166:1822-1828
Patients cared for at the right time, at the right place.