Transition from hospital to home or sub-acute care facility

The three phases on which you will focus are: • Transition from hospital to home or sub-acute care facility o Discuss the HRRP readmission reduction plan. o Provide introduction to your patient and discuss pre-discharge initiative/interventions to promote optimal recovery and prevent readmission within 30 days or less. • Reduction of all-cause, non-disease-specific readmissions o Research and discuss evidence-based practices for effectively transitioning patient from facility to home with specific focus on preventing all-cause hospital readmissions. o Incorporate social determinants of health considerations that impact all-cause readmissions and how to prevent them with focused interventions or initiatives for your patient targeting the individual, community, and system levels. • Primary, secondary, and tertiary strategies to prevent hospitalization o Research and discuss approaches to impact/reduce hospitalization utilizing primary, secondary, and tertiary prevention initiatives focusing on the individual, community, and system level specific to your patient’s condition or procedure.