From: Evaluation of a modified community based care transitions model to reduce costs and improve outcomes
 | Total Number | Percent |
---|---|---|
Reported averted care visits (hospital or office) | 11 | 45.8 |
Appointment assistance | 10 | 41.7 |
Follow up appointment(s) scheduled | 21 | 87.5 |
Transportation to appointment(s) in place | 20 | 83.3 |
Follow up scheduled within 7 days | 10 | 41.7 |
Follow up scheduled with specialist | 19 | 79.2 |
Medication reconciliation | 21 | 87.5 |
Medication education | 21 | 87.5 |
Education on condition red flags | 22 | 91.7 |
Education on condition specific information | 22 | 91.7 |
Received individualized care plan | 22 | 91.7 |
Hospital A referrals | 12 | 50 |
Hospital B referrals | 12 | 50 |
Reported unplanned care visits | 5 | 20.8 |
Depression screening completed | 10 | 41.7 |
Mobility screening completed | 10 | 41.7 |