Table 1 Model of the modified care transitions intervention: the Four Pillars
Pillar | Medication self-management | Follow-up | Red flags | Patient-centered health record |
|---|---|---|---|---|
Goal | Know medications & have system to take them | Schedule appropriate follow-up visits | Know indications that a condition is worsening and how to respond | Understand and manage a personal health record |
Home Visit | Discuss importance of knowing medications Reconcile medications; correct discrepancies | Emphasize importance of follow-up visit; practice and role-pay questions for the PCP | Discuss symptoms and side effects of medications | Explain the personal health record Review discharge summary; encourage patient to share health record with PCP |
Follow-up calls | Answer any remaining medication questions | Advocate for getting an appointment, if needed | Reinforce when/if PCP should be called | Discuss outcome of PCP visit |