Care Transitions Program

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

• The patient's discharge paperwork​ from the facility

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