What do we hope to accomplish?
Who is our target population?
How will we do it?
Metric: The number of participating patients with a care transition plan developed prior to discharge.
Scope of Intervention: The Care Transitions workflow will be inclusive of dual-eligible Medicaid and Medicaid Managed Care patients with a high risk stratification score and/or an unplanned readmission. The Care Transitions team may prioritize adult patients age 18+ with the following chronic diseases or factors in its approach:
Commitment: Through DSRIP Years 1-4, the target number of actively engaged Care Transitions patients is per below:
Note: A discharge needs to be accompanied by a Care Transitions plan in order for that patient to count as ‘actively engaged’.
Note: A patient may not count toward the actively engaged goal more than once in a DSRIP year.