Wooster Community Hospital CCN Screening and Patient Identification

1. Wooster Community Hospital CCN Screening and Patient Identification • Identification Sources: • CCN – Date Review • Practitioner Identification • Community Referral • Screening Site: • Hospital • Patient’s Home • Practitioner’s Office In-Patient Screening Identification Start Data Review Chronic Diagnosis Other Diagnosis Review patient’s Healthcare Utilization Screen (refer to diagram below) If > 2 hospitalizations or ED visits in last 6 months OR If history of chronic medical problem yes no Screened No Utilization Not Screened Screening Program introduction and Overview Program interest expressed Decline screening Risk tool performed No further action END No needs Needs identified Obtained consent No further action Consent signed Refused Complete CCN Care Plan and notify PCP of enrollment in program Offer Follow-Up phone call