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Answers


Patient understanding discharge plan

• Explain /review the PatientCare Connex™ Program
• Review/confirm understanding of the discharge plan
• Utilize the teach-back methods (patients own words)
• Discharge Summary may not be completed
• Telephone support

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Schedule follow-up appointments

• Schedule appointments
• PCP Transition of Care reimbursement
• Provide schedule transportation
• Identify any barriers of transitional care

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Schedule outpatient procedures 

• Identify lab work and tests pending
• Send to HCP reviewing results
• Gather/send results from tests performed at hospital

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Arrange Post-Discharge Services 

• Collaborate with case management
• Obtain information regarding approved vendors
• Therapy and/or Durable Medical Equipment (DME)

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Medication Reconciliation 

• Voucher 2-day supply (if needed)
• 30-day supply of discharged medications
• Patient Rx insurance formulary
• Communicate with patients medical team

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Educate the Patient 

• Educate patient on their diagnosis
• Pull-through hospital education
• Follow hospital disease state management protocol

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Language Services 

• Preferred language
• Arrange for language services as needed
• Interpreter and translation services

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After Hospital Care Plan (AHCP) 

• Explain and perform teach-back with patient/caregiver
• Provide snap shot of patients hospital/SNF stay for PCP
• Sent prior to follow-up appointment
• Discharge Summary may not be completed
• Telephone support

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Problem Solving 

• When to call 911
• When to call your Primary Care Physician (PCP)
• When to call PHARxSIGHT

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Adherence Programs 

• SMS Text, IVR
• E-mail communication
• Medication Therapy Management (MTM)
• Fill Rx’s 31st day and beyond

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