1. Using the Post Discharge Call Survey to Support Members Transitioning from Hospital to Home

2. Supporting our Members as they Transition from Hospital to Home
12/6/2018
Supporting our Members as they Transition from Hospital to Home
In-home Care Managers play an important role in supporting members during the critical time they transition from hospital to home.
Most readmissions occur within the first few days of discharge.
Many members are discharged home with poor understanding of their medications, discharge, and/or follow-up instructions and/or do not have the resources and services in place to transition successfully from hospital to home. 2

3. You may be the first person in the member’s life to show that you care
12/6/2018
Case Scenario
A member was discharged from the hospital and the CM called the member to evaluate for post discharge needs and worked with the member to resolve identified needs. The member called the CM’s manager to report the following:
“Through the years I have been on several in home type programs and the CM is the only one who has taken the time, listened, and really showed that she cared – it’s because of the CM that I am finally feeling better.”
The member used the words persistent, consistent,
and superb when talking about the CM.
You may be the first person in the member’s life to show that you care
Let’s see the new tool in Rosalind that will assist you in producing this kind of success story. 3

4. Introducing the Post Discharge Call Survey (PDC)
12/6/2018
Introducing the Post Discharge Call Survey (PDC)
What Did We Do?
Why Did We Do It?
What is the Impact?
Added Post Discharge Survey to the “Programs” Tab to complete on the first verbal contact with the member once they are in the home setting.
The goal is to see the member within 48 hours of discharge. Follow current process for outreach attempts:
First attempt within 24 hours of referral receipt
Make at least 4 total contact attempts, at various times of the day, over the next 5 days of receiving the referral.
Currently:
Post discharge evaluation occurs at the time of the home visit, several days after the date of discharge.
There is not a place to formally evaluate and document the critical elements that keep from preventable readmissions.
Completing the Post Discharge Survey at the first verbal contact will help build rapport, so the member will say “Yes!” to the home visit.
Improve member experience by timely identification of urgent unmet needs and supports “Show Me you Care” value.
Improve CM experience by PIONEERING SIMPLICITY to have a place to evaluate and document key areas to support a member at discharge. 4

5. This is what the new Post Discharge Survey will look like!
12/6/2018
Let’s check out the new Post Discharge Call Survey tool that will help you create the kind of success story that energizes you!
This is what the new Post Discharge Survey will look like! 5

6. Finding the Post Discharge Call Survey in Rosalind!
12/6/2018
Finding the Post Discharge Call Survey in Rosalind!
Step 1: Log into Rosalind Step 2: Go to ‘Clients’ and select ‘Client Data’ Step 3: Go to the ‘Program’ tab Step 4: Select ‘HUMTR’ from ‘Branch’ drop down list Step 5: Select your member in the ‘Member’ drop down list Step 6: Select ‘Show Notes’ to see Special Instructions from the referral source Step 7: Post Discharge Survey will populate  click ‘Show Survey’ 6

7. Let’s Take a Look at the Post Discharge Survey and Process
Use the Post Discharge Survey and Transitions Post Discharge Process and Talking Points Guide to facilitate your conversation with the member.
Post Discharge Survey:
Transitions Post Discharge Process and Talking Points Guide:
The above Post Discharge Survey.pdf and Transitions Post Discharge Process and Talking Points Guide.pdf are printable.

8. Post Discharge Survey Documentation Considerations
Note:
Document within 24 hours
You can save an incomplete survey by clicking ‘Save’
You will receive errors if you hit ‘Processed’ and the survey is not complete

9. Printing the Post Discharge Survey
The Post Discharge Survey is printable from the Programs Tab in Rosalind or the .pdf file(s) in this training presentation
Click on the printer icon in the Programs Tab
DO NOT click ‘Printable Version’ in the upper right hand corner. This will only print the current screen.

10. Let’s Document in the Activity Note!
12/6/2018
Let’s Document in the Activity Note!
Answer the red questions appropriately in the ‘Activities Characteristics’ section.
Check the appropriate selection on ‘What Was Done’
Post D/C Tool/Survey Complete = Member reached and Post Discharge Survey Completed
Post D/C Tool/Survey Contact = Member reached and Post Discharge Survey Not Completed 10

11. Let’s Document in the Findings/Interventions Box (examples):
12/6/2018
Let’s Document in the Findings/Interventions Box (examples):
Post Discharge Call Survey Complete/Member Visit Scheduled: Phone call to member’s home number xxx-xxx-xxxx, this morning.  Spoke with member. Introduced  self and Transitions services. Member reports she was discharged from the hospital yesterday. Post Discharge Survey complete. Member’s <<recap member’s urgent unmet needs>> addressed. Member agrees to home visit tomorrow morning. Post Discharge Call Survey Complete/Member Refused Transitions: Phone call to member’s home number xxx-xxx-xxxx, this morning.  Spoke with member. Introduced  self and Transitions services. Member reports she was discharged from the hospital yesterday evening and is settled in at home.  Member reports her daughter, Jane, is staying with her from out of town until member gets back on her feet. Post Discharge Survey complete. Member’s <<recap urgent unmet needs>> identified and will need follow-up on <<whatever urgent unmet needs were not addressed>>. Member declined home visit. 11

12. 12/6/2018
Let’s Document in the Findings/Interventions Box (examples): Post Discharge Call Survey Not Complete/Member Visit Scheduled: Phone call to member’s home number xxx-xxx-xxxx, this morning.  Spoke with member. Introduced  self and Transitions services. Member reports she was discharged from the hospital yesterday. Unable to complete Post Discharge Survey. Member agrees to home visit tomorrow morning. Post Discharge Call Survey Not Complete/Member Refused Transitions: Phone call to member’s home number xxx-xxx-xxxx, this morning.  Spoke with member. Introduced  self and Transitions services. Member reports she was discharged from the hospital yesterday evening and is settled in at home.  Member reports her daughter, Jane, is staying with her from out of town until member gets back on her feet. Member declined to complete Post Discharge Survey and home visit. 12

13. Documenting for Continuity of Care
12/6/2018
Documenting for Continuity of Care
IMPORTANT:
Any documentation added to the ‘Comments’ or the ‘Additional Notes’ section in the Post Discharge Survey needs to be documented into the Activity Note.
If the Post Discharge Call Survey was complete and the member declined the home visit, you’ll need to document the identified unmet needs, what unmet needs were addressed, and what unmet needs are unresolved. This will inform the telephonic care manager of needs that need to be addressed.
If the Post Discharge Call Survey was not complete and the member declined the home visit, you’ll need to document member declined both. This will inform the telephonic care manager they need to complete Post Discharge Survey.
Document within 24 hours. 13

14. Next Steps
12/2/15: Post Discharge Call Survey will be visible in Rosalind (evening).
Begin using the Post Discharge Call Survey at the first verbal contact to help build rapport, so the member will say “Yes!” to the home visit.
Use the Post Discharge Call Talking Point Guide to guide your conversation.
Follow current process for outreach attempts. The goal is to see the member within 48 hours of discharge.

15. Commitment to Learn