Long-Term and Post-Acute Care Providers Engaged in Health Information Exchange: Final Report. Attachment H-1. PERFECT Form

10/29/2013

PATIENT NAME: _________________________   DISCHARGE DATE: _________________________   SOC DATE: _________________________  
HOME HEALTH AGENCY: _________________________
HH CASE MANAGER CONTACT # (if different): _________________________  
SOC RN CONTACT #: _________________________
TELEMONITORING AVAILABLE?: _____ Yes  _____ No  

The PERFECT Form is a communication and accountability tool developed to encourage collaboration after hospital discharge between home health partners and the clinical team at RUSH. The information provided by the admitting RN in the field provides a critical snapshot of the patient in their home environment and helps us define care expectations for a successful transition from hospital to home.

How to use the PERFECT form:

  • Please check yes or no for each of the care expectations listed
  • Utilize the interventions column as a guide for addressing problem areas
  • Use the comments section to provide any additional information
    • Actions taken to resolve a problem
    • Additional information about a situation
  • Please contact Madeleine Rooney, MSW at RUSH at 312-942-6995 within 48 hrs. if any issues remain resolved or if any delay in care is present
  • Fax completed form to 312-563-6548 within 72 hrs. of admission to the agency
  • Attach additional comments on separate pages as neede

Hand off communication is essential to assure quality coordination of care.

    Care Expectations Interventions Additional Information
Plan of Care ___ Yes  
___ No
Plan of care discussed with pt. & family/ consent for care signed?
  • Plan reviewed with pt/family
  • Schedule left with pt/family
  • Emergency contact info provided
  • Teaching initiated for at risk Dx.
  • BRIDGE MSW contacted to discuss health literacy concerns &/or scheduling barriers
  • Interdisciplinary communication established
Note any special orders:
___ Yes
___ No
Health literacy issues identified at SOC?
___ Yes
___ No
Barriers to scheduling visits present?
Equipment/ Supplies ___ Yes
___ No
Provided within expected timeframe?
  • Dressings &/or supplies provided at initial visit
  • Teaching initiated
  • Pre-discharge equipment obtained
  • Post D/C DME ordered
DME Provider #:
___ Yes
___ No
Additional DME needs?
___ Yes
___ No
Telemonitoring needed?
Reconciliation of Medications ___ Yes
___ No
Pt has dc instructions?
  • BRIDGE MSW contacted to fax dc instructions
  • Meds reconciled
  • At risk meds identified
  • Teaching initiated
  • Provide Pillbox
  • Missing meds obtained/reported to MD and BRIDGE MSW w/in 1 day
  • BRIDGE MSW contacted for help to resolve medication access issues
  • Home delivery of medications needed
Pharmacy #:
___ Yes
___ No
D/C list match meds found in home?
___ Yes
___ No
RN contacts patient w/in 24 hrs-missing meds obtained
___ Yes
___ No
Pt. able to obtain meds w/out barriers? Who fills the pillbox?
___ Yes
___ No
Pillbox in home?
___ Yes
___ No
Are medications adequately managed?
Follow Up MD ___ Yes
___ No
MD appt scheduled within 10 days?
  • Confirm pt's MD follow-up appt & plan to attend
  • Notify BRIDGE MSW of scheduling or transportation barriers
  • Arrange Home Physician as needed
PCP #:

MD Appt:

MD Appt:

MD Appt:

___ Yes
___ No
Can pt physically get to the appt?
___ Yes
___ No
Is transportation available for f-up appt.?
Expectations ___ Yes
___ No
Is patient satisfied with discharge plan and services provided? 48 hour quality assurance call completed  
Caregiver & Support ___ Yes
___ No
Is primary caregiver available?
  • Assess caregiving stressors
  • CNA ordered
  • MSW ordered
  • Assess for homemaker/ private pay services
  • MD office contacted PRN
Caregiver:
___ Yes
___ No
Community resources needed? Pt Support:
___ Yes
___ No
Were community resources arranged prior to d/c? Contact #:
Therapy ___ PT
___ OT
___ ST
___ None  
Therapies provided w/in 72 hrs unless otherwise ordered? Contact MD if additoinal orders needed  

 

Was RN visit performed 24 hrs post D/C? ___ Yes  ___ No
___ Patient/family declines care ___ Unsafe environment ___ Family refuses out of network co-pay
___ Care exceeds capacity ___ No skilled need ___ Patient re-hsopitalized before first visit  
___ Unable to local patient ___ Patient not discharged from hospital   ___ Insurance out of network
___ Cancelled by referral source   ___ Another agency providing services ___ Referred to another agency
 

 

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