MSHO/MSC+ Post Discharge Assessment Form

Instructions: Complete one Post Discharge Assessment Form upon return to the member’s usual setting for each discharge from a hospital or long term care facility. All sections must be completed. Return via Right Fax to

952-853-8744.

General Information HealthPartners Member ID: Member Last Name: Member First Name: Date Notified of Actual Admission (MM/DD/YY): Date of Admission (MM/DD/YY): Reason for Admission: Type of Admission: ER/ Observation only Regular setting to hospital Regular setting to NF for LTC Regular setting to SNF/TCU for rehab Regular setting to hospital Regular setting to outpatient setting
Discharge to Regular Setting Date of D/C to Regular Setting: New Chronic Condition(s) list: Date POC Shared / PCP Notified: Care Plan Sharing Method: Verbal to Clinic Fax EMR Other (list): Physician F/U Appt. Status: In 7 days of DC In 8 – 15 days of DC In 16 or > days of DC NA – Patient back to inpatient setting No – MD advised no appointment needed No – Patient declined, encouragement/assistance/education provided
Outreach Date of call to patient/family (MM/DD/YY): Abe to reach patient/family/caregiver? Yes No No Patient Contact Reason: Attempted UTR, wrong disconnected phone number Attempted UTR, left message, no call back Attempted UTR, no answer, no voice mail Patient Terminated Patient Deceased
Medication Review If Reached, Were Meds Reviewed? Yes No If no, what was the reason? (select one) Member decline medication review: Yes No Attempted and found patient with no medications knowledge: Yes No Attempted and found patient with no medications ordered: Yes No Attempted and unable to review medications for other reason: Yes No Other reason:
Education to Prevent Readmission Provided (select one) Yes Red flags for readmission were reviewed and none present Yes Red flags for readmission were reviewed and one or more present No Attempted to review red flags for readmission, member declined education No Attempted to review red flags for readmission, unable to provide education for other reasons If red flags noted, indicate No follow- up appointment Knowledge deficit related to medications Knowledge deficit related to signs/symptoms of worsening condition Barriers related to following recommended treatment plan
Care Coordinator Intervention(s) CC Intervention Assessment indicates no need, none provided Education re: importance of PCP follow up appointment Education re: CareLine (612-333-2229) Facilitated follow-up appointment Facilitated same-day appointment Provide health education Communicated with Care Team Other (please describe):
Member Changes as a Result of this Care Transition Changes as a Result of this Care Transition Functional: Yes No Cognitive: Yes No Medical: Yes No Psychosocial: Yes No Mental Health: Yes No Notes: Care Plan updated: Yes No Teach Back Method Used: Yes No
Date: Care Coordinator Signature