Smooth transitions from the hospital or the emergency department to home are critical for patient safety and reducing readmissions. Providers play a key role in ensuring patients receive timely follow-up and support to aid in these transitions.
Why it Matters:
- Timely follow-up within 7 days of discharge can significantly reduce readmissions.
- Clear communication and care coordination improve outcomes and patient satisfaction.
Best Practices for Transitional Care:
- Schedule follow-up visits within 7 days of discharge.
- Review discharge details: reason for admission, test results, instructions, and medication reconciliation.
- Engage caregivers: confirm support at home and address health related social needs.
- Provide clear, written discharge plans in the patient’s preferred language.
- Encourage patient participation: use teach-back, goal setting, and shared agendas.
Resources for Patients:
- CCA care team: Call 866-610-2273 to be connected to your patient’s care team and learn more.
- CCA Healthwise website: Visit cca.healthwise.net for self-management tools.
- Community Resources: Mass 211, FindHelp, Project Bread Food Source Hotline, Executive Office of Housing and Livable Communities (EOHLC) Resource Locator, Massachusetts Association for Community Action (MASSCAP), and more can help with for housing, food, and social needs.
Your Role:
- Share these resources during visits or discharge planning.
- Collaborate with CCA care managers for complex cases.