Module 2: SummaryExpected Outcomes

• Identify patients who are members of the project’s targeted population
• Alert the DA about new patients
• Screen for final acceptance into project
• Initiate discharge planning on admission
• Meet the patient (through the care team, admission notes, and in person)
• Initiate care plan and maintain activities log
• Participate in daily rounds with health care team to plan patient education and post-discharge services
• Visit patient daily and educate during each visit
• Continue to add to Patient Care Plan

Notes:

In this module, we reviewed several activities related to the re-engineered discharge program.