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MA STAAR Fall Learning Session Early Assessment of Post-Hospital Needs

MA STAAR Fall Learning Session Early Assessment of Post-Hospital Needs. 1:15-2:30PM Breakout Massachusetts General Hospital and Sturdy Memorial Hospital Patricia Rutherford, Kate Bones. IHI’s Roadmap for Improving Transitions and Reducing Avoidable Rehospitalizations.

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MA STAAR Fall Learning Session Early Assessment of Post-Hospital Needs

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  1. MA STAAR Fall Learning SessionEarly Assessment of Post-Hospital Needs 1:15-2:30PM Breakout Massachusetts General Hospital and Sturdy Memorial Hospital Patricia Rutherford, Kate Bones

  2. IHI’s Roadmap for Improving Transitions and Reducing Avoidable Rehospitalizations Improved Transitions and Coordination of Care Reduction in Avoidable Rehospitalizations or * Additional Costs for these Services Patient and Family Engagement Cross-Continuum Team Collaboration Evidence-based Care in All Clinical Settings Health Information Exchange and Shared Care Plans

  3. Key Changes to Create an Ideal Transition Home • Perform an Enhanced Assessment of Post-Hospital Needs • Provide Effective Teaching and Facilitate Enhanced Learning • Ensure Post-Hospital Care Follow-up • Provide Real-Time Handover Communication

  4. Perform an Enhanced Assessment of Post-Hospital Needs • Involve the patient, family caregiver(s), and community provider(s) as full partners in completing a needs assessment of the patient’s home-going needs. • Reconcile medications upon admission. • Identify the patient’s initial risk of readmission. • Create a customized discharge plan based on the assessment.

  5. What is one new thing you learned today that you would like to test?

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