Care Transitions Community Provider Survey

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1. From your experience, why do you think that patients with multiple chronic conditions (i.e. Congestive Heart Failure, Diabetes, etc.) are being readmitted to the hospital? Please check all that apply.

From your experience, why do you think that patients with multiple chronic conditions (i.e. Congestive Heart Failure, Diabetes, etc.) are being readmitted to the hospital? Please check all that apply.   Patient didn’t understand what medication to take or took medication incorrectly Patient’s condition worsened and didn’t know what else to do but go to the hospital Patient didn’t follow up with physicians/specialists timely Patient didn’t understand discharge plan or wasn’t provided needed information upon discharge Patient didn’t have needed social service supports Patient didn’t receive medical follow-up prescribed upon discharge, i.e. medical tests, specialist referral, treatment, etc. Other

(Please specify below)

2. Are there common concerns about succeeding at home that you hear from your patients before discharge?

Are there common concerns about succeeding at home that you hear from your patients before discharge?

3. From your experience, what can we do to improve how patients transition from one level of care to another to reduce the rate of avoidable hospital readmissions and improve quality of care? Please check all that apply.

From your experience, what can we do to improve how patients transition from one level of care to another to reduce the rate of avoidable hospital readmissions and improve quality of care? Please check all that apply.   Provide health self-management education to patients during and after discharge Improve communication across different levels of care and providers Link patients during and after discharge to home and community based services like transportation, in-home care, home delivered meals, case management, etc. Make physician and specialist follow-up appointments prior to discharge Call patients after discharge to see how they are doing Fill prescribed medications prior to discharge Provide more detailed information at the time of discharge Refer patients to health-self management, nutrition and fall prevention education programs Other

(Please specify below)

4. From your experience, what type of health and social service supports are most often needed by a chronically ill patient that is returning home following a hospitalization? Please check all that apply.

From your experience, what type of health and social service supports are most often needed by a chronically ill patient that is returning home following a hospitalization? Please check all that apply.   Home health Follow-up appointment with primary care physician Follow-up appointment with specialists Appointment reminders Medical tests and procedures scheduled prior to discharge Health and health self-management education Medication dispensing devices Health monitoring devices Care coordination Home delivered meals In-home care Homemaker services Transportation Housing Caregiver support/respite Grocery delivery Durable Medical Equipment not covered by insurance Adaptive technology/equipment Home modification Legal, financial or insurance assistance Other

(Please list below)

5. Care transition is defined as the movement of patients from one health care practitioner or setting to another as their condition and care needs change. What kind of care transition practices are you are aware of that have demonstrated a reduction in the readmission rates for chronically ill patients?

Care transition is defined as the movement of patients from one health care practitioner or setting to another as their condition and care needs change. What kind of care transition practices are you are aware of that have demonstrated a reduction in the readmission rates for chronically ill patients?