Key el­e­ments of CCNC’s tran­si­tional-care in­ter­ven­tions

Modern Healthcare - - BEST PRACTICES -

Pa­tient and fam­ily mem­bers are taught to iden­tify red flags that in­di­cate when it’s time to call the doc­tor, care man­ager or in-home ser­vice provider.

Care man­agers are trained in mo­ti­va­tional in­ter­view­ing tech­niques to strengthen the like­li­hood of be­hav­ioral changes.

In­for­ma­tion shared with pri­mary-care providers con­nects the dots on hos­pi­tal­iza­tions, pre­scrip­tions, so­cial needs and other rel­e­vant con­cerns.

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