Ryan Sparks | Nexus Health Resources

Variables to Consider for Stratifying the Risk of Readmission

While there are multiple models for stratifying patients on their risk of readmission, many providers find that they need to customize the models to fit the nuances of their communities. The following infographic provides a guide to the most common factors to consider in a readmission risk model, including: Overall health and function Mental health…

Simple Tips for Discussing Goals of Care with Patients

Simple Tips for Discussing Goals of Care with Patients Many seasoned transitional care coordinators recognize that a care plan should consider the personal motivators that encourage patients to take an active part in their recovery. To identify those unique triggers, it helps to apply a patient-centered approach that is rooted in motivational interviewing. The aim…

Proposed Quality Measure Includes Focus on Care Transitions

CMS recently released their report “List of Measures under Consideration for December 1, 2017”. One proposed measure directly applicable to transitional care is the CoreQ: Short Stay Discharge Measure. The measure calculates the percentage of individuals discharged in a six-month time period from a SNF, within 100 days of admission, who are satisfied. This patient…

A Guide to Successful Patient Conversations

A Guide to Successful Patient Conversations 4 Common Personality Traits + Simple Dos and Don’ts Sales people often modify their proposals based on the specific wants and needs of their customers. This same approach can be applied in transitional care to improve communication with your patients and their family members. Patients and care givers…