Care transition involves a set of interventions aimed at optimizing coordination of services, information continuity and enhanced communication to provide appropriate, safe and timely care following discharge from inpatient and observation care. Major components of care transitions include patient and caregiver education, medication reconciliation, coordination and arrangement of care in the post-acute care setting, aiding communication among healthcare professionals, and use of evidence-base protocols.
This tool assesses structural, environmental, safety and security related elements that are necessary for patients to reside in their residences and, if appropriate, receive care in their home setting. The greatest feature of this tool is that the completion of the assessment will automatically generate a suggested action plan to address the findings. This is the only tool that automatically generates an action plan based on the assessment findings.
A comprehensive tool that streamlines the process of ordering Home Healthcare services, document provided services, and instruct for how to inform the ordering practitioners of the patient's progress.
The only available tool that allows assessment and follow-up care for Palliative Care services. The tool also contains an action plan that allows documentation and communication for the planned interventions.
Designed to serve as a guide to assess the patient's fall risk factors through physical examination, observation and interaction with the patient.
Designed to assess Patient and/or Caregiver's engagement as a very useful tool to initiate an effective care plan in the pre to post discharge continuum of care.
Intended to assist with effective discharge planning to provide care information continuity following discharge from the acute and subacute care settings.
Allows social workers to perform and document an accurate and thorough in-home assessment. The assessment includes evaluation of mental, emotional, cognitive, social determinants of health and environmental factors. The tool also includes a summary section which is extremely valuable as it can be used to provide feedback to the ordering practitioner and other providers involved in the patient's care. Designed to initiate intake and screening with careful documentation of the implemented steps and an up-to-date summary of relevant information.
Evidence-based tool created to independently assess patient's mental functions, basic and industrious ADLs, is the only tool of its kind that assesses and scores patient’s basic and industrious daily activities, and allows objective longitudinal comparisons. The tool allows long-term monitoring of change of status and assists with provision of correct services at the most appropriate level of care.
Creates an accurate and complete record of all medications that are taken by the patient following an admission to inpatient level of care. The tool may also be completed during transition of care process, care in the outpatient setting (hospital observation care), following transfer to another health care facility, or as part of care coordination by community providers.
• Manage PCP and pharmacy information
• Easy to complete medication list from a complete data base of brand and generic drugs
• Compliance, adherence, side effects and interactions survey
• The reconciled medication list and generated action items can be shared with patient and other providers