Improvement: Transitions of Care: Making it Better

Course overview

Rural hospitals work with multiple care settings as a patient discharges from acute care, but few assist the patient in navigating through multiple settings. Intermingled with health services is the opportunity to engage social support systems invested in helping the person beyond the boundaries of a hospital. Rural hospitals have at their disposal not only the opportunity to build innovative coalitions but the data that defines innovative approaches to health and human services. There is no right way or one way to approach transitions in care, but by using creative approaches and building both health-related and community services partnerships 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 the strengths of the discharge planning process Describe gaps in discharge planning choices Identify services support for discharged patients Identify hospital discharge data for planning Explain how to Initiate a community coalition program Recall next steps to "make it better" 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.