Next Step in Care: Family Caregivers & Health Care Professionals Working Together

Toolkit: Closing the Communciation Loop


Follow-up with the Next Setting of Care

Preventing or alleviating problems with patient transitions through effective post-discharge communication with the next setting of care.


Staff Survey: Closing the Loop

Points to Consider: Was the next setting of care able to pick up the patient's care seamlessly, given the information sent? Were there delays in care provision due to inadequate or ineffective communication regarding the patient's care needs or the family caregiver's role, availability and other responsibilities, and traning needs?


Follow-up with the Family Caregiver

Contacting the family caregiver after discharge to learn about and address any critical issues that might lead to adverse outcomes for the patient or unecessary burden on the family caregiver.


Project RED's How to Conduct a Post-Discharge Follow-up Phone Call

Care Transitions Intervention's Care Transitions Measure (CTM):
     15-question version
     3-question version

Teach Back

Points to Consider: Now that the patient has transitioned to another care setting (home, inpatient rehab, etc.), does the family caregiver still have a good understanding of the medication regimen, red flags, and what actions to take regarding red flags or other concerns? Have follow-up appointments been kept, or does the family caregiver need assistance? Does the family caregiver understand the purpose of the follow-up appointments? The person following up with the family caregiver should have a strong knowledge of both the patient's and the family caregiver's needs and situations.


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