Best Practices for Transitions of Care

As flu season arrives and the threat of COVID-19 continues, smooth transitions of care for your patients are more vital than ever. This fall and winter, make sure to prioritize post-discharge follow-up visits when appropriate and via telehealth when necessary. The following timeline of key post-discharge activities will help you stay on track:

  • 24-48 hours post hospital/post-acute discharge—Phone call to patient
  • 2-14 days post hospital/post-acute discharge—Make an appointment with primary care
  • For high risk patients: 10-14 days post hospital/post-acute discharge—Follow-up phone call
  • All patients: 25-30 days post hospital/post-acute discharge—Follow-up phone call

VHAN staff can help your practice offer more personalized and effective care to all of your patients. This can include helping you streamline medication lists, improve access to care, offer community resources and support your patients’ long-term health goals. Our Care Management Team is made up of highly trained nurses, pharmacists and licensed clinical social workers who act as an extension of your practice, providing you with additional clinical support such as:

  • Community resource and service coordination (i.e. transportation, meal delivery, adult daycare, caregiving, etc.)
  • Comprehensive medication reconciliation and reviews
  • Liaison with Skilled Nursing Facilities, Durable Medical Equipment and home health providers to ensure patient needs are met
  • Disease and symptom management education

VHAN’s interdisciplinary approach to care management has yielded impressive results, with outreach to more than 7,700 patients. Building on an existing relationship with the Tennessee Hospital Association (THA), VHAN is one of the first population health management organizations to stand up a program utilizing the Admission, Discharge and Transfer (ADT) feeds from all member hospitals to identify patients who need care management assistance after discharge.

Recently, VHAN operations and clinical staff participated in the American Medical Group Association’s Medicare Advantage (MA) Learning Collaborative, an 18-month peer sharing program on how to maximize effectiveness of MA and value-based contracts. VHAN staff shared the successes of the network’s Transitions of Care Program and found this unique member benefit differentiates VHAN from similar networks. Visit the Hub to learn more about VHAN’s Transitions of Care program or download the Transitions of Care toolkit.

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