30-day Readmission Review

Observed Date

Is the Index Admission Diagnosis a chronic condition?

Discharge disposition from index admission

Number of days since prior admission

Have there been 4 or more hospitalizations at DCMH in last 12 months for this patient?

Was a patient interview completed?

Insurance

Patient Interview

Unable to obtain or take prescribed medications

Patient or caregiver did not understand discharge instructions

Symptom relief for chronic condition

Unable to attend follow-up appointment

SNF sent patient to ED for physician assessment

Unable to access basic needs such as food, transportation, housing

Chart Review

Documentation that a medication list was provided to patient or caregiver at discharge

Information about the patient's condition was documented and provided to the next level of care receiver

For patients with a comorbid behavioral health condition, a follow-up appt with a behavioral health provider is documented

For patients that require assistance from social services, a direct linkage documented instead of asking patient to self-navigate

The primary learner/caregiver is identified and documented in the medical record

Teach-back is documented when discharge education is provided

Care transition plan included info about obtaining and taking medications

Care transition plan included info about s/sx and what to do if they occur

Care transition plan included a scheduled follow-up appointment and was documented in the discharge packet

Care transition plan included plan for transportation to get to the follow-up appointments

Care transition plan included follow-up labs or tests

A post-discharge phone call is documented

List other reasons contributing to readmission as stated by patient

Audit Form