Care Transitions Program

Program Components

  • Follow up phone call scripts including core questions facilities are required to follow

    • 48 hours post discharge

    • 14 days post discharge

    • 30 days post discharge

  • Metric log

    • Assists in tracking a true 30 day post discharge readmission rate​

  • Letter to Primary Care Physician at time of discharge

    • Patient's discharge paperwork​ from the facility

    • Information on continued services i.e. Home Health, outpatient therapy, etc.