Care Transitions Information for SCAN Providers
Care Transitions is an evidence-based, short-term telephonic case management program with specific intervention strategies designed to prevent readmissions and ensure safe and coordinated transitions across the care continuum. A SCAN Care Transition Coach (Nurse or Social Worker) assists the member/advocate in taking an active role in the self-management of their condition and coordination of both planned and unplanned transitions.
Based on the “Care Transitions” model developed by Eric Coleman, MD, MPH the SCAN program focuses on five key elements:
- Medication reconciliation across care settings
- How and when to respond to warning signs/symptoms
- Ensuring post discharge MD follow up visits are scheduled and occur
- A personal health record (PHR) to convey information between settings
- Advanced care planning to assist end of life discussion and decision making
When a planned or unplanned transition occurs, SCAN encourages Provider Groups to provide each member who experiences a transition with a consistent person or unit within the organization responsible for supporting the member through transitions between any points in the system and to implement the following procedures:
Provider discharging/sending member
- Notify the members’ usual practitioner of the transition within 3 business days.
- Communicate with the receiving facility by sending the member’s plan of care within 1 business day of notification of the transition. Information to be exchanged may include:
- Medical status
- Current medication list
- Functional status (Baseline and Current)
- Cognitive status (Baseline and Current)
- Self-Care ability
- Social support
- Living arrangements (prior to episode and future plan)
- Communication (language, literacy and health beliefs)
- Advance Directives (Power of Attorney for Healthcare)
- Durable Medical Equipment needs
- Identify that transition is going to happen and communicate with the member or member’s advocate about the care transition process and how their health status and plan of care will be impacted.
Provider receiving member
- Confirm receipt of plan of care and other information with sending provider
- Review all information from sending provider
- Contact sending provider with questions or concerns regarding transition or member status prior to receiving the member
- Share member information with appropriate staff in receiving care setting
- Use information from sending provider in development of plan of care for your setting
SCAN Care Transition Coaches collaborate with members and their health care providers to develop and implement a coordinated care plan, which considers the member’s previous level of function, cognitive status, place of residence, diagnosis, prognosis, and end-of-life issues. During and after the transition the health coach provides education and assistance around the five key elements (described above). The health coach validates that the member/caregiver understands, agrees with and can act on the treatment plan and goals of care.
In addition to working with members and/or advocates, SCAN provides additional information, training, support and tools to providers upon request.
SCAN Transition Tools
My Medicine Record – Help members in transition keep track of multiple prescription and OTC medications with this useful list and schedule.
Personal Health Record – A one-page document for members/caregivers to use in managing a transition from hospital or skilled nursing facility to home.
My Doctor Visit Checklist – Post- transition, encourage members to make, keep and prepare for follow up visits to maintain health and avoid re-admissions.
Care Transitions http://www.caretransitions.org
Advance Directives http://www.agingwithdignity.org
For more information or assistance please contact our Care Transitions Supervisor
Debbie Welch, LVN
(562) 637-7357 Dwelch@scanhealtplan.com