
VitaCare AAA Re-hospitalization Protocol
Vitacare triple A re-hospitalization protocol (Agency Action on Avoidable Re-hospitalization Protocol) will ensure that patients discharged from area hospitals and skilled nursing facilities will receive continued home care based on transition of care best practices.

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Visit the high risk patient in the hospital or skilled nursing facility before discharge and contact the patient within 24 hours of discharge form the hospital.
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If at any time the patient requires medical treatment, the home health nurse will contact the Primary Care Physician and obtain medical orders.
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Provide follow-up care for 3 weeks after the assessment visit, either by a visit if the patient is receiving home health care or by telephone if the patient has not met the criteria for home health care.
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Comprehensive assessment on the first visit and plan follow-up care as needed. Emphasis on:
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Use an integrated approach to assess each patient at risk for readmission
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Perform a comprehensive risk assessment with disease specific indicators
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Incorporate self-management tools into daily practice
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Reconcile medications and customize a Medication Action Plan
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Monitor and manage the use of medication at all times
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Activate fall prevention plan based on multi-factorial fall risk assessment
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Assess and evaluate functional status and ability to safely remain at home.
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Promote follow-up with physicians within 7 to 10 days post discharge
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Educate on identification of signs and symptoms of disease exacerbation
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Assist the patient to maintain a Personal Health record
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Conducts standardized Depression screening every visits
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Assess health literacy
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Administer pneumonia vaccine as indicated
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Improve communication agency wise related to patient high risk status
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