The three phases on which you will focus are:
• Transition from hospital to home or sub-acute care facility
o Discuss the HRRP readmission reduction plan.
o Provide introduction to your patient and discuss pre-discharge initiative/interventions to promote optimal recovery and prevent readmission within 30 days or less.
• Reduction of all-cause, non-disease-specific readmissions
o Research and discuss evidence-based practices for effectively transitioning patient from facility to home with specific focus on preventing all-cause hospital readmissions.
o Incorporate social determinants of health considerations that impact all-cause readmissions and how to prevent them with focused interventions or initiatives for your patient targeting the individual, community, and system levels.
• Primary, secondary, and tertiary strategies to prevent hospitalization
o Research and discuss approaches to impact/reduce hospitalization utilizing primary, secondary, and tertiary prevention initiatives focusing on the individual, community, and system level specific to your patient’s condition or procedure.
