Care transition definition
Care transition means the transfer or transition of a patient
Care transition means a service provided to support acute care hospital discharge of an older individual that resides in Kitsap or has a desire to return to Kitsap County, at the direction of the older individual or a family member of the individual, to assess the needs, and to arrange, coordinate, and monitor an optimum package of services to address the needs, of the older individual. Care Transitions includes services and coordination such as:
(1) Telephonic comprehensive assessment of the older individual (including the physical, psychological, and social needs of the individual); and
(2) Development and implementation of a service plan with the older individual or their family member, friend, and/or informal support to mobilize available formal and informal resources and services identified in the assessment to meet the needs of the older individual, including coordination of the available resources and services, per the older adult’s choice.
(a) With any other plans that exist for various formal services, including hospital discharge plans; and
(b) With the information and assistance services provided under the Older Americans Act.
(3) Coordination of formal and informal service delivery, including at least one follow-up contact with the older adult or their identified informal supports, to ensure the services specified in the plan are being provided, as per the older adult’s choice and availability;
(a) Periodic reassessment and revision of the status of the older individual with:
i. the older individual; or
ii. if necessary, a primary caregiver or family member of the older individual; and
iii. in accordance with the wishes of the older individual, advocacy on behalf of the older individual for needed services or resources.
Care transition means the transfer or transition of a patient from an urgent care facility to a health care or behavioral health care provider.
More Definitions of Care transition
Care transition means the transfer or transition of a patient from one health care or behavioral health care provider to another.