13. Common Process Breakdowns Resulting in Potentially Avoidable Readm

Common Process Breakdowns Resulting in Potentially Avoidable Readmissions (continued)

• Poor transfer of information to patient:
  • Poor patient understanding of how to use medications after hospital discharge.
  • Patient doesn't understand warning signs that warrant an emergency call to their physician.
• Poor transfer of information to ambulatory caregivers:
  • Hospital to nursing home staff.
  • Hospital to primary care physician.
  • Lack of clarity on end of life care preferences.

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