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On discharge day, our nursing team, led by Rae Ann Mayer, BSN, RN-BC, CCP, reviews medications, activity level, and social determinants of health with patients. We establish a personalized Plan of Care (POC) and schedule a Transition of Care (TOC) visit, collaborating with home care and disease navigators. Our focus includes reinforcing chronic disease self-management using the Heart Failure Zone Tool, evaluating follow-up appointments, discussing goals of care, and providing ongoing support to patients and caregivers. We also identify high-risk patients in our EHR for proactive management.
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Safe Landings Rae Ann Mayer, BSN, RN-BC, CCP
Discharge Day 1 • Review Meds, activity, social determinants of health • Establish POC (Plan of Care) • Schedule TOC (Transition of Care) • Collaborate with Home Care, and Disease Navigators • Reinforce chronic disease self management
Participate in TOC visit • Review Medications • Evaluate follow up appointments with specialists • Reinforce therapeutic goals • Goals of Care discussion • Care Manager meets patient and family
Longitudinal Care • Care Team Meetings • Review progress to goals, and barriers • Refer to team members as appropriate • Identify High Risk patients in EHR • Care Manager assists in triaging concerns of these patients • Ongoing support to patient and caregiver
