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Care Transitions During COVID Response Period

Catholic Medical Partners and Catholic Health Systems (CHS) are partnering to do transitions of care “warm handoff” for our high risk patients who have either visited the Emergency Department at a CHS site or have been admitted and are now being discharged from an inpatient unit at a CHS site. Discharge destination will be home for these patients. The profile of patient that the hospital Care Management team will be focusing on are our high risk patients who meet one (or more) of the following criteria:

  • patient at risk for readmission
  • patient at risk for adverse event after discharge
  • patient discharged on new high risk medications
  • patient with a high risk diagnosis (COPD/Uncontrolled diabetes)
  • pending important test results
  • patient needing immediate close monitoring by PCP

What to expect:

The Primary Care office will be contacted by the CHS Hospital Care Manager to do a warm handoff and to schedule a follow up visit with Primary Care. Due to the staffing changes during the past two weeks, the contact information of the practice managers has been given to the hospital team as a first point of contact. If the primary care office has a Care Manager, the expectation would be that the Care Manager would receive the hand off, if there is no Care Manager currently, the practice manager would redirect the Hospital Care Manager to the appropriate clinical staff to receive the warm hand off.

Please prepare to receive calls from the Hospital Care Managers effective Monday April 6th. This is an opportunity for our practices to obtain information re: hospital visits and to allow for follow up in near real time via telemedicine. Please note that the Hospital Care Managers will be providing the warm hand off using the Situation-Background-Assessment-Recommendation (SBAR) framework.