TRANSITION SUPPORT

Chris Walker, MSN, RN, MHA

Director

Inpatient Mental Health Units/Behavioral Access Nurses

READMISSION RATES

FY 2012 = 12.25%

PATIENT/FAMILY ENGAGEMENT & ACTIVATION

Family support

Teach back method

Health literacy

Releases of information

MEDICATION MANAGEMENT

Medication reconciliation

Patient medication list

Medication availability

Patient agreement and understanding

COMPREHENSIVE TRANSITION PLANNING

Transition plan

CARE TRANSITION SUPPORT

Follow-up appointment

Community resources

Follow-up phone call

TRANSITION COMMUNICATION

Hand off communication

Discharge summary

READMISSION RATE

FY 2013 = 9.32%

QUESTIONS???