October 8, 2013
Ensuring that effective communication occurs between primary care and other care providers, like hospitals, home care, home, specialty care, skilled nursing facilities, or rehab is a key element in successful care transitions and reducing avoidable readmissions. Interventions may include establishing processes for the transfer of information, defining accountability for care, communication of the plan of care, and methods for talking directly with sending or receiving caregivers, as well as defining key information like current health status, follow-up needs, pending test results, red flags, medications, and special patient needs. Based on the work of the No Place Like Home Campaign, this presentation focuses on the roles and responsibilities primary care should have in care transitions.
- Identify typical transition communication failures that occur when a patient transfers across settings
- List effective strategies a primary care home can use to improve care transitions
- Translate the best practices to meet PCPCH standards for specialized care setting transitions and referral and specialty care coordination
Stacy Moritz, RN, MBA
Director of Medicare Quality Services
With Acumentra Health since 1994, Stacy has developed work plans for complex projects, specializing in strategic partnerships and marketing. She has taken part in nationwide collaborative QI projects involving diverse healthcare professionals and stakeholders in Oregon, Washington and Minnesota. She developed Achievable Benchmarks of Care reports to provide performance data to clinics and Medicaid managed care plans in Washington. As Director of Medicare Quality Services since 2005, Stacy manages all activities in the company’s Medicare Quality Improvement Organization contracts and leads the community-based QIO project on reducing hospital readmissions.
Archives of Internal Medicine Report - Communication Discrepancies Between Physicians and Hospitalized Patients
American Medical Association (AMA) Report - There and Home Again, Safely: 5 Responsibilities of Ambulatory Practices in High Quality Care Transitions
Medication Brown Bag Review, Health Literacy Universal Precautions for Primary Care
Patient handout - “What can I do to live as well as I can with my health condition?” which links patients to these resources
Patient handout “How can I partner with my doctor on my health care?” which links patients to these resources
|Care Setting Transitions Webinar Slides||1.29 MB|
|Care Setting Transitions Responses to Discharge Question.docx||13.19 KB|