RED Component |
DE Responsibilities |
1. Ascertain need for and obtain language assistance. |
- Find out about preferred languages for oral communication and written materials.
- Determine patient and caregivers’ English proficiency
- Arrange for language assistance as needed, including translation of written materials.
|
2. Make appointments for followup medical appointments and post discharge tests/labs. |
- Determine primary care and specialty followup needs.
- Find a primary care provider (if patient does not have one) based on patient preferences: gender, location, specialty, health plan participation, etc.
- Determine need for scheduling future tests.
- Make appointments with input from the patient regarding the best time and date for the appointments.
- Instruct patient in any preparation required for future tests and confirm understanding.
- Discuss importance of clinician appointments and labs/tests.
- Inquire about traditional healers and assure that traditional healing and conventional medicine are complementary.
- Confirm that the patient knows where to go and has a plan about how to get to appointments; review transportation options and address other barriers to keeping appointments (e.g., lack of day care for children).
|
3. Plan for the followup of results from lab tests or studies that are pending at discharge. |
- Identify the lab work and tests with pending results.
- Discuss who will be reviewing the results, and when and how the patient will receive this information.
|
4. Organize post-discharge outpatient services and medical equipment. |
- Collaborate with the case manager to ensure that durable medical equipment is obtained.
- Document all contact information for medical equipment companies and at-home services in the AHCP.
- Assess social support available at home.
- Collaborate with the medical team and case managers to arrange necessary at-home services.
-
|
5. Identify the correct medicines and a plan for the patient to obtain and take them. |
- Review all medicine lists with patient, including, when possible, the inpatient medicine list, the outpatient medicine list, the outpatient pharmacy list, and what the patient reports taking.
- Ascertain what vitamins, herbal medicines, or other dietary supplements the patient takes.
- Explain what medicines to take, emphasizing any changes in the regimen.
- Review each medicine’s purpose, how to take each medicine correctly, and important side effects.
- Ensure a realistic plan for obtaining medicines is in place.
- Assess patient’s concerns about medicine plan.
|
6. Reconcile the discharge plan with national guidelines. |
- Compare the treatment plan with National Guidelines Clearinghouse recommendations for patient’s diagnosis and alert the medical team of discrepancies.
|
7. Teach a written discharge plan the patient can understand. |
- Create an AHCP, the easy-to-understand discharge plan sent home with patient.
- Review and orient patient to all aspects of AHCP.
- Encourage patients to ask.
|
8. Educate the patient about his or her diagnosis. |
- Research the patient’s medical history and current condition.
- Communicate with the inpatient team regarding ongoing plans for discharge.
- Meet with the patient, family, and/or other caregivers to provide education and to begin discharge preparation.
|
9. Assess the degree of the patient’s understanding of the discharge plan. |
- Ask patients to explain in their own words the details of the plan (the teach-back technique).
- May require contacting family members and/or other caregivers who will share in the care-giving responsibilities.
|
10. Review with the patient what to do if a problem arises. |
- Instruct on a specific plan of how to contact the primary care provider (PCP) by providing contact numbers, including evenings and weekends.
- Instruct on what constitutes an emergency and what to do in cases of emergency.
|
11. Expedite transmission of the discharge summary to clinicians accepting care of the patient. |
- Deliver discharge summary and AHCP to clinicians (e.g., PCP, visiting nurses) within 24 hours of discharge.
|
12. Provide telephone reinforcement of the Discharge Plan. |
- Call the patient within 3 days of discharge to reinforce the discharge plan and help with problem-solving.
- Staff DE Help Line. Answer phone calls from patients, family, and/or other caregivers with questions about the AHCP, hospitalization, and followup plan in order to help patient transition from hospital care to outpatient care setting.
|
