A serious issue in healthcare today is the need to close communication gaps that are often experienced during transitions of care. These gaps place patients with multiple chronic conditions at risk for negative health outcomes and increased caregiver burden. The older population is especially vulnerable to these challenges.
This presentation will explore potential interventions, processes, tools, and resources that can be utilized to help ensure timely, appropriate, and safe discharge to the next level of care. The interventions and processes discussed are designed to facilitate communication and coordinate care for members transferring from one care setting to another, provide nurse interaction with the member and family, establishing two-way communication, acting as patient advocate, and ensuring that care needs are met through the care continuum.