CPSC Care Transition Sub-Team

The CPSC Care Transition Sub-Team is our largest sub-team. There are many multi-diverse health care professionals participating in order to best address patient safety issues across the continuum of care. The sub-team consists of Executive Directors, Compliance/Regulatory Officers, Directors of Case Management, Discharge Planners, Directors of Quality, Directors of Admissions, Directors of Emergency Services, Home Health/HOSPICE Agencies, Nursing and Rehabilitation Facilities, Assisted Living Facilities, Educational Institutions, County Medical Society, Ambulance Providers and County Board of Health. The Sub-Team also collaborates with Medical Directors, Physicians, Hospitalists, ER Physicians and Palliative Care Physicians and Practitioners. Some initiatives may require collaboration with other CPSC Sub-Teams and/or health care professionals. The CPSC Care Transition Sub-Team initiatives are:

• Identified and developed a hand-off communication tool and checklist to be used throughout the community and across organizations to ensure conveyance of critical patient information during the transfer process
• Standardize Ancillary Orders Set for Heart Failure Patients
• Develop Standardized Heart Failure Education materials to be adopted across the continuum of care
• Develop Standardized Palliative Care Education Tools and Launch Community Education Campaign
• Promote education to the public regarding the contraindications of herbs, supplements and vitamins with medications
• Promote effective communication between physicians and healthcare providers during the transfer process
• Improving medication reconciliation during transition of care NOTE: This was in collaboration with the CPSC Medication Safety Sub-Team
• Develop Standardized Pulmonary Care Education tools to be adopted across the continuum of care
• Educational Program to Sub-Team regarding CRE