Transition Home

Patient Care Goals         

Identify patients who are at risk for readmission by 1) identifying knowledge gaps in their discharge instructions 2) identifying lack of follow-up appointments 3) identifying fall risks in the home and 4) helping patients understand their medicines.

Clinical Management Options

EMT-B

•Make sure the patient has all discharge meds prior to leaving the hospital •Review the patient’s discharge instructions with them on the way home. •Answer as many questions as possible •Identify if the patient has a follow-up appointment. •Put a note of the appointment on the fridge/add to a calendar if available •Identify if they have transportation to the follow-up appointment •Identify and remove fall risks from the home •Refer all patients who have no follow-up, no transportation, poor understanding of their discharge instructions, or who you feel are high risk for readmission to the MIH Program

Paramedic

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Rules 

• Please document the Discharge Comprehension Assessment and the Fall Safety Assessment in your chart as you interview the patient.
• Please refer patients you identify as high risk (many fall hazards, patients who don’t have follow-up or have a poor understanding of their discharge instructions) to the MIH program.
  • Do this by sending an email to Kate Allinder with the patient’s name and DOB
• It is important to document in your chart WHY you had concerns. It allows the MIH team to reach out and fix the specific needs you noticed.