Becker's Hospital Review: 10 Key Components Of A Post-Discharge Care Model

1. Assure that there is close and trusted interaction between the outpatient care team and the hospital discharge planners
2. Begin the patient-interaction portion of the program with a post-discharge in-home assessment
3. Meet with the primary care physician
4. Conduct weekly interdisciplinary team conferences
5. Provide specialized care and considerations for common geriatric conditions
6. Consider the unique physical and psychosocial needs of low-income seniors including dual eligibles
7. Focus not only on treating a person's medical condition but for managing a broad array of care needs across multiple settings
8. Ensure that your program includes a focus on patient education
9. Have the information technology infrastructure in place
10. Continue to monitor the patient's progress

Source: Becker's Hospital Review
Source URL: http://www.beckershospitalreview.com/quality/10-key-componen...

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