Patient Receives Care in the ED or 23/59 Observation Unit Hospital Care Summary (electronic/faxed SNF and/or PC) Hospital/ED Schedule Patient Appointment (see triage) (if discharge to home) Reinforce Discharge Plan Including Medication Reconciliation Patient Education Provider Feedback to Hospital SMOOTH COMMUNICATIONS OVERVIEW Cohesive plan of care between transitions at arrival and discharge from the hospital (Stay of less than 24 hours) DRAFT Community/ Provider Forum to Discuss Effectiveness Role of Primary Care (PC) Provider or SNF Role of Hospital/ED 1.What happens prior to hospital care? 2.What happens during hospitalization? 3. What happens at discharge? 4.What happens post discharge? Follow up by PC Ensure Appointment (see triage) 3 4

Patient Receives Care in Hospital PC Notified of Admission Discharge Plan (electronic/faxed SNF and/or PC) Hospital Follow Up Call to Patient Hospital Schedule Patient Appointment (see triage) (if discharge to home) Reinforce Discharge Plan and Medication Reconciliation Patient and Care Giver Education Provider Feedback to Hospital Patient and Care Giver Communication Specifics on Discharge Plan including Medications Education SMOOTH COMMUNICATIONS OVERVIEW Cohesive plan of care between transitions at arrival and discharge from the hospital (Stays more than 24 hours) DRAFT Community/ Provider Forum to Discuss Effectiveness Role of Primary Care (PC) and SNF Role of Hospital 1.What happens prior to hospital care? 2.What happens during hospitalization? 3. What happens at discharge? 4.What happens post discharge? Follow up by PC Ensure Appointment (see triage)

Smooth Communications – Transitions in Care Discussion Questions 1.What happens when the patient does not have a primary care provider? Do we need a separate flow diagram and agreed upon expectations for who does what and when in this situation which is fairly common? How will this change the expectations regarding appointments and the timing of follow-up? 2.Do we need specific, agreed-upon criteria that will guide the clinical triage of patients at the time of discharge? Or, is it okay to leave this to the clinical judgment of the discharging provider? 3.What strategies are likely to be most effective in building accountability and responsiveness among community physicians for their proactive participation in the patient hand-off’s? What are the barriers for community physicians and how can we overcome them most effectively? What do community physicians need to be most effective? 4.Are hospitals/emergency departments organized and resourced in the most effective way to effectively facilitate the hand-off’s and provide information? What do hospitals/emergency departments need to be most effective?