Implementation: Transitions of Care: Making it Real

Course overview

Rural settings have multiple layers of health care and social support services to draw on for patient care and coordination. Using the hospital/swing bed program as the organizer, this is an opportunity to initiate or enhance one of two projects: building/maintaining a community-wide working committee to address patient needs following health care issues; OR initiate or enhance an aging in place project. Both projects are designed to help patients after discharge from acute or swing bed to help them maintain their health and independence with the provision of community services - hospital to transportation, coordination between hospital services and other health providers, assistance with life and social needs being addressed. The patient is assisted into the right setting at the right time with the right support needed. Suggested audience: CFOs, CNOs, COOs, Case Managers, Discharge Planners, Social Workers, Swing Bed Managers, Home Health Managers, Outpatient Rehab Managers If you have any questions regarding this course, please contact hthtech@hometownhealthonline.com. Upon completion of this presentation, you should be able to: Define use of data for projects Identify other sources of data Recall community coalition basics Describe aging in place projects Discuss ways to initiate or enhance community projects Recall next steps for success Learning Outcomes Standard: Based upon hospital specific data as well as current research from Agency for health Research and Quality; Alzheimer's Association; American Society of Hospital Pharmacists; CMS Medicare and Medicaid Services; HUD Community-Centered Solutions for Aging at Home; Council on Aging; Medicaid Eligibility and Aging in Place; Rural Health Information Hub; US Census Bureau Population Projections. Learning Outcome Conditions: As an IACET Authorized Provider, HomeTown Health, LLC offers CEUs for its programs that qualify under the ANSI/IACET Standard. HomeTown Health, LLC is authorized by IACET to offer 0.1 CEU for this program. A full list of approved IACET organizations can be found on www.iacet.org. In order to receive 0.1 CEU credit/ 1 credit hour for this course, you must: Complete course in its entirety. Complete course within 30 days. Pass all assessments with an 80% or better. Complete Online Course Evaluation. Handouts provided in the Digital Library. Definitions for course terms are included in the HTHU GLOSSARY.