A Description And Defense Of The Change

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3. A description and defense of the change in policy, procedure or program Description: Detailed Process mapping for coordination of care Developing strategies to achieve ideal transition in care can be described as better “discharge planning, complete communication of information, availability, timeliness, clarity and organization of information, medication safety, educating patients to promote self-management, advance care planning, coordinating care among team members, monitoring and managing symptoms after discharge and follow up” (Kripalani et al., 2014) The Proposed program focuses on the one critical process of coordination of care – timely communication for timely follow-up plan and follow-through after discharge by designated…show more content…
Also providing list of resources that can help physician to make a follow up appointment for patient. • Highlighted area for physician to mandatory fill in to identify who is going to be the primary attending physician to resume patient’s care at SNF after discharge ( as well as confirmed date and time for follow up appointment with physician. Also filling in the follow up location, such as at clinic, at SNF etc. • Lastly, there is an option for physician to choose “no confirmed appointment” that will automatically create the list of patients who does not have appointment for follow up at the time of discharge. Arm 2. Who: Hospitalist/Physician at acute-care hospital When: Prior to give discharge order for patient who will be discharged to SNF Where: at acute-care hospital What: • Initiate the process of making and confirming an appointment for patient. • Communicate appropriate discipline to coordinate care How • Supported by decision support system • Communicate/coordinate follow up care with appropriate discipline, especially making follow up appointment. • Helped to recognize and identify the patient who has no appointment at the time of discharge. Arm 3. Who: Nursing Staff/Care coordinator at hospital When: prior or after receiving discharge order
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