A transition of care summary, also known as a discharge summary, provides essential clinical information for the receiving care team and helps organize final clinical and administrative activities for the transferring care team. This summary helps ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location. This document improves transitions and discharges, communication among providers, and cross-setting relationships which can improve care quality and safety.
Several factors must be addressed to assure a good outcome and prevent a readmission. Factors that may increase the risk of readmission include:
- Diagnoses associated with high readmissions
- The need for numerous medications
- A history of readmissions
- Psychosocial and emotional factors, such as issues relating to mental health, interpersonal relationships, or family matters
- The lack of a family member, friend or other caregiver who could provide support or assist with care
- Older age
- Financial distress
- Deficient living environment
Our “Clinical Population Management” activities implemented within the model are interdisciplinary communication, planning for proper support and accommodations after discharge, and advanced education aimed at the patient’s specific condition.
Our trained clinical staff will work with the hospitals to receive timely data ( ADT Files) and engage the patient as well as all appropriate care management team members or institutions in order to facilitate the transition and reduce any errors. This can eliminate 72% or hospital readmissions that are due lack of data sharing upon transitions.