Navigating the Rapids of Transition Management
Sharol Herr, Clinical Manager Palliative Care Services – Key Contact
Linda Bentley, RN, MSN, CNP, ACHPN
Mount Carmel Health System
1144 Dublin Road
Columbus, Ohio 43215
| << previous | next >> |
(Click on poster to view full image in pop up window)
Description
Recognizing the challenges of Transition Management, Mount Carmel Health has developed several strategies to improve transitional care from acute care to the outpatient setting.
In this presentation we will share a brief review of:
The language and principles of effective transition management
Barriers and challenges to transition management
Strategies implemented for transition management
- Hospital to palliative skilled care in ECF (Extended Care Facility)
- Hospital to home/ECF with hospice
- Skilled ECF to hospice
- Hospice home care to hospice general inpatient care
- Skilled ECF to hospital
Roles and responsibilities of the palliative care and hospice interdisciplinary team members
- Communication
- Medication reconciliation and management
- Patient and family education and involvement in planning for post-acute care
- Palliative education of community care providers
- Identify potential high-risk red flag concerns
| << previous | next >> |
