1. The Bucks-Chester-Montgomery Link Hospital to Home Four simple steps to make sure that when you get home – you stay home.

2. What is a care transition? - Anytime you move from a place where somebody is taking care of you to a place where you are taking care of you. -For example: Discharged from the hospital or a rehabilitation center or leaving a nursing home or assisted living facility.

3. Why do I need to know this? 19% of people over the age of 65 will be readmitted within 30 days of discharge. 24.1% of Medicare beneficiaries between the ages of 18-64 will be readmitted within 30 days of discharge Between 10-11% of people with private insurance between the ages of 18-64 will be readmitted within 30 days of discharge.

4. What could go wrong when I go home? The key areas that present the most problems: – Lack of a personal health record for the transition (a Patient Pass) – Medication mix-ups and side-effects – Not understanding symptom red flags – No doctor’s visit within 7 days

5. What is a Patient Pass? The Patient Pass is a simple one page form that will help you manage the transition from hospital to home. It is not your complete medical record It contains very focused information on risk factors. It can be read and understood by anybody. It will be visible to anybody who comes into your home to help you.

6. What should I know about Medication Management? Did you receive a new prescription from the hospital? If so, is it meant to take the place of an old one? Do any new medications have side-effects you need to monitor? Did your pharmacist look at your new list of medications and reconcile them with your old medications? Did you dispose of discontinued medications?

7. Symptom Red Flags What are your red flags? Can you effectively monitor your red flags? Do you need a scale to record your weight? Or a blood pressure cuff to monitor your blood pressure? If you notice a red flag, should you wait and see? Should you call the doctor? Should you go to the emergency room or call 911?

8. A doctor visit within 7 days The longer you wait to go to the doctor, the higher your risk for re-admission to the hospital. Did you or someone else make an appointment within 7 days? Will you be able to get there? Take your patient pass with you! The doctor may not yet have all the information from the medical facility.

9. How can I remember all that? Your Patient Pass will be in the flash drive on your key-chain. Remember this simple phrase to remind yourself why it’s there and what it’s for: Don’t – D is for doctor’s appointment Re-Admit – R is for red flags Me – M is for medication management

10. The flash drive The flash drive contains a Patient Pass (personal health record) and can go on your key-chain. The Patient Pass clearly communicates the key risks and has room for new medications, red flags and a doctor’s appointment. The Patient Pass clearly communicates what information needs to be gathered.

11. How do I use the flash drive? Put it on your key-chain so it is always with you. Tell family, friends and caregivers about it. Show your doctor at your next regular visit. If you do go to the hospital, tell the staff, your family and anyone else who is there to help you that you want it printed and filled out when you are ready to go home.

12. You’re Home! Now… – Did you post your Patient Pass in a visible location? – do you understand which medications to start and which to stop? Did your pharmacist review your new medications for you? – Do you understand your symptom red flags and what to do about them? – Did you make a doctor’s visit within 7 days of getting home?

13. What if I don’t feel well enough to manage all this? The truth is, you may not. But if you can alert just one responsible person who is with you during this transition event, they should be able to fill out and help you monitor your Patient Pass. The important thing is that either you or somebody helping you is aware of the risks of a transition and what to do about them.

14. Now that you’re home… Stay Home! Bucks-Chester-Montgomery Link Hospital to Home Project