Clinical Considerations
Review of Hospital Course and Pending Tests
Conduct thorough review of the hospitalization, including diagnoses, procedures, unresolved tests, and labs requiring follow-up.
Comprehensive Medication Reconciliation
Ensure accurate reconciliation of all medications, with attention to patient comprehension, affordability, access, and adherence.
Patient Management
Active Coordination & Communication
Position primary care as central to care coordination, ensuring timely referrals, information exchange, and a unified plan of care.
Education Using the "Teach-Back" Method
Confirm the patient has an understanding of the care plan by having them (and/or their caregivers) restate key instructions in their own words.
Assessment of Social & Functional Barriers
Evaluate SDOH considerations (e.g. transportation, food security, caregiver support, home safety) that influence care plan success.
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