Safe Landings Rae Ann Mayer, BSN, RN-BC, CCP

1. Safe Landings Rae Ann Mayer, BSN, RN-BC, CCP

2. Discharge Day 1 • Review Meds, activity, social determinants of health • Establish POC (Plan of Care) • Schedule TOC (Transition of Care) • Collaborate with Home Care, and Disease Navigators • Reinforce chronic disease self management

3. Heart Failure Zone Tool

4. Participate in TOC visit • Review Medications • Evaluate follow up appointments with specialists • Reinforce therapeutic goals • Goals of Care discussion • Care Manager meets patient and family

5. Longitudinal Care • Care Team Meetings • Review progress to goals, and barriers • Refer to team members as appropriate • Identify High Risk patients in EHR • Care Manager assists in triaging concerns of these patients • Ongoing support to patient and caregiver