Table 2.
Care Component | Description | n (%) |
---|---|---|
Care coordination | Organize follow-up testing and appointments with primary care and other healthcare providers to best meet patient’s needs and preferences. | 181 (57.1) |
Health promotion counseling | Provide support and guidance to improve patient’s understanding and control over their health by making positive changes (e.g., attitudes, behaviors [diet, smoking cessation, exercise], environment). | 116 (36.6) |
Emotional listening | Listen and offer emotional support for patients to promote shared understanding of the patient’s recovery experiences, build rapport, trust, and social connection during recovery, and enhance care. | 100 (31.6) |
Symptom management | Screen for new or increasing limitations in activities of daily living, physical functioning, cognitive changes, and mental health symptoms. Provide resources or referrals to address identified needs. | 81 (25.6) |
Medication management | Review medications with the patient and/or caregiver. Reassess medications changed during hospitalization and adjust for physiologic changes secondary to acute illness. | 93 (29.3) |
Chronic disease management | Assess status of chronic illnesses (e.g., CHF, COPD, diabetes), address disease information needs to promote self-management, and confirm optimal therapy to enhance control. | 91 (28.7) |
Addressing social determinants of health | Screen for social support needs related to housing, food, medications, and transportation. Refer to social worker or other community assistance programs as needed or available. | 78 (24.6) |
Care setting advice and guidance | Support patient’s recovery with information and advice on when and where to seek care. | 70 (22.1) |
Primary palliative care | Provide basic, palliative-focused supportive care and management to patients with serious illness. Refer to palliative care specialists, if appropriate. | 10 (3.2) |
Definition of abbreviations: CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease.