Figure 2.

Basics of Care Transition Programs

Care Transition Metrics = readmission, recurrent thromboembolic events, bleeding, follow up visits, primary care provider (PCP) or specialist contacted, discharge summary of hospitalization in 24 hours Staff (nursing, pharmacy, physicians), Residents, and Medical Students trained and involved in care transition processes

Disease Management = management of diseases requiring anticoagulation

Discharge Summary = Dictated within 24 hours of discharge

Patient and Family= Education program for patient and family

Follow up Appointments and Calls = Follow up appointments with primary care physician, specialists, anticoagulation program

Contact PCP or Specialist = Phone call placed at time of discharge to PCP and specialists