Transition Care

Assessing Patient Help

Providers need to make sure that the patient and their care giver can perform self care activities, eat an appropriate diet, follow up with designated providers, and obtain and self-administer medications.

Organizing Home Services

Visiting nurses, personal care, infusion providers, and other in home services need to be referred to and post-pandemic in home care cases can take up to a week to be successfully opened.

Discharge Planning, Summary, and Checklist

Patients need to be discharged at an appropriate time, with the appropriate services, and signed off from the appropriate providers all while receiving a thorough and easy-to-understand summary of stay.

Patient Instructions

Discharge education needs to explain: "Why was I in the hospital?" "How so I manage at home?" "What should I do if I run into problems?" "Why is in important for me to do this?"

Teachbacks

Discharge teams verify patient and care giver knowledge multiple times by asking questions about a discharge summary and patient instructions: "What is your understanding of your heart problem?"

Medication Reconciliation

Teams need to make sure that the patient's biggest responsibility of their own - taking their medications properly - is explained, understood, and that the prescriptions they are leaving with are accurate.

Medications provided at discharge and hand-delivered to patients to their home setting

Medication adherence tools and solutions

Medication reconciliation and safety review

Clinical pharmacist follow-up

24/7 on-call support

Quality metric analysis, closure assistance, and goal setting

Seamlessly integrates into facility workflow

Home-based team follow up and support

8.9%

30-Day Readmission Rate, compared to 21.3% control group

98%

Medication Adherence - Including 98% PDC in cholesterol and diabetic measures

23%

Reduction in ER-Visits

97%

Of Patients Continued to use Centennial for 90-days or more