Daim Ntawv Qhia Tag Nrho-Cause Readmissions Tip Sheet

Measure Description:

Tus naj npawb ntawm cov tswv cuab hnub nyoog 18 xyoo thiab tshaj saud nrog tus neeg mob mob hnyav thiab kev soj ntsuam nyob hauv lub xyoo ntsuas tom qab los ntawm kev npaj tsis tau npaj rau kev kuaj mob hauv 30 hnub.

Kev txhawb siab

Kev cais tawm

Cov tswv cuab tswj hwm nyob rau hnub Index Discharge Date.
Dual kev pab them nqi cov tswv cuab.
Cov tswvcuab hauv tsev khomob, tau txais kev pabcuam tsev khomob, lossis cov neeg tuag thaum lub xyoo ntsuas.
Kev mus pw hauv tsev kho mob hnyav nrog ib qho ntawm cov hauv qab no ntawm daim ntawv tso cai tawm:
- Ib qho kev kuaj mob tseem ceeb ntawm cev xeeb tub lossis mob perinatal.
- Lub tsev kho mob tau npaj tseg siv ib qho ntawm cov hauv qab no:
  - Kev kuaj mob tseem ceeb ntawm kev kho tshuaj kho mob.
  - Kev kuaj mob tseem ceeb ntawm kev kho mob.
  - Kev hloov pauv hauv lub cev (lub raum, pob txha pob txha, lub cev, thiab kev taw qhia rau autologous pancreatic cells).
  - Muaj peev xwm npaj cov txheej txheem yam tsis muaj kev kuaj mob tseem ceeb. Piv txwv li, coronary artery bypass, tso dej ntawm sab sauv, thiab fusion ntawm lub lumbosacral sib koom ua ke yam tsis muaj kev kuaj mob tseem ceeb.

Cov ntaub ntawv sau

Kev Pab Cuam Rau Kev Nyeem Ntawv

Raws li phau ntawv Journal of Family Practice, feem ntau pab txhawb rau kev nyeem ntawv yog:

Xav tias tsis npaj rau kev tso tawm.
Nyuaj ua haujlwm txhua hnub.
Nyuaj nkag mus rau cov tshuaj tso tawm.
Teeb meem adhering rau tso tshuaj.

Tsis muaj kev txhawb nqa. Kev tshawb pom los ntawm Lub Chaw Haujlwm Saib Xyuas Kev Noj Qab Haus Huv thiab Kev Ua Zoo qhia tias cov neeg mob Dub thiab Neeg Mev muaj kev paub ntau dua ntawm kev zam kom tsis txhob nyeem ntau dua li cov neeg mob Dawb. Ntau yam tuaj yeem ua rau muaj qhov tsis sib xws hauv kev nyeem ntawv, suav nrog:

Kev txwv kev hais lus thiab nkag mus rau cov neeg txhais lus.
Kev paub txog kev noj qab haus huv.
Culturally competent neeg mob kev kawm.
Social determinants ntawm kev noj qab haus huv.
Kev puas hlwb.
Comorbidities.

Cov kev coj ua zoo tshaj plaws

Qhia txhua tus tswv cuab rau:
- Hu rau lawv lub chaw ua haujlwm PCP txhawm rau teem caij ntsib tom qab lawv tawm hauv tsev kho mob.
- Hu rau Alliance Nurse Advice Line: 1 (844) 971-8907, muaj rau txhua tus tswv cuab ntawm Alliance 24 teev nyob rau ib hnub, 7 hnub hauv ib lub lis piam, yog muaj lus nug lossis kev txhawj xeeb tshwm sim thiab lawv tsis tuaj yeem ncav cuag lawv tus PCP.
- Siv Nug Kuv 3^®: Cov Lus Nug Zoo rau Koj Kev Noj Qab Haus Huv Zoo thaum mus ntsib txhawb kom lawv nug peb cov lus nug tshwj xeeb ntawm lawv cov kws kho mob kom nkag siab zoo dua lawv cov kev mob nkeeg thiab lawv yuav tsum ua dab tsi kom noj qab haus huv.

1. 1. Kuv qhov teeb meem loj yog dab tsi?
  2. Kuv yuav tsum ua dab tsi?
  3. Vim li cas nws tseem ceeb rau kuv ua qhov no?³

Siv tsib yog vim li cas kom tau txais kev pom los ntawm cov tswv cuab kom nkag siab txog yam uas coj lawv mus rau hauv tsev kho mob. Piv txwv li, kev xam phaj yuav qhia tau tias ib tug tswv cuab tsis noj nws cov tshuaj, uas ua rau nws rov mus pw hauv tsev kho mob.
- Vim li cas nws tsis noj nws cov tshuaj? Nws tsis coj nws vim nws tsis muaj.
- Vim li cas? Nws tsis tau khaws nws ntawm lub tsev muag tshuaj.
- Vim li cas? Nws tsis muaj tsheb thauj mus rau lub tsev muag tshuaj. Txuas ntxiv nug kom txog thaum koj tau txheeb xyuas cov sijhawm uas koj pab neeg tuaj yeem hais tau.⁴
Muab cov neeg ua haujlwm kho mob rau:
- Saib xyuas lub Linked Members Inpatient Admissions qhia rau ntawm Tus kws kho mob Portal ua ib qho cuab yeej los taug qab cov tswv cuab txuas uas nyuam qhuav tau mus pw hauv tsev kho mob.
- Hu rau cov neeg mob uas nyuam qhuav tso tawm los ntawm kev kho mob hauv tsev kho mob kom coj lawv mus rau kev mus ntsib tom qab. Qhov no tuaj yeem ua tiav los ntawm kev mus ntsib kev noj qab haus huv thiab suav rau Post-Discharge Care CBI ntsuas. Qee lub tsev kho mob tau ua tiav cov sijhawm ua ntej rau kev mus ntsib tom qab.
- Siv qhov kev mus ntsib tom qab los qhia tus neeg mob hais txog nws qhov kev kuaj mob thiab tshuaj thiab tshuaj xyuas qhov qib ntawm tus neeg mob qhov kev nkag siab ntawm cov phiaj xwm tso tawm thiab cov tshuaj. Cov txheej txheem ua tiav suav nrog kev siv cov Qhia-Rov Method txhawm rau txhim kho tus neeg mob nkag siab thiab ua raws.
- Hu rau tus neeg mob ob peb hnub tom qab tso tawm mus xyuas kom rov hais dua txoj kev npaj saib xyuas thiab xyuas nrog tus tswv cuab. Kev hu xov tooj tom qab tso tawm tau pom tias yuav txo tau cov tsev kho mob nyeem ntawv thiab ua tau zoo tshaj plaws nyob ze rau hnub tso tawm.
- Taug qab thiab hloov kho koj lub tsev kho mob cov neeg mob uas muaj kev phom sij tshaj plaws. Sim ua ntau yam kev nthuav tawm rau cov neeg uas tsis yooj yim tshaj plaws ua ntej lawv raug nyeem. Rau cov tswv cuab uas muaj kev pheej hmoo siab ntawm kev nyeem ntawv, muab:
  - Kev kho tshuaj kho mob.
  - Kev cob qhia kev tswj tus kheej rau cov tswv cuab thiab cov neeg saib xyuas los pab cov tswv cuab txheeb xyuas thaum twg los tswj kev puas tsuaj loj thiab thaum twg yuav nrhiav kev saib xyuas raws sij hawm los ntawm lawv tus PCP.

Cov peev txheej

Alliance Cultural thiab Linguistic Services muaj rau cov neeg muab kev pabcuam network.
- Language Assistance Services – thov cov ntaub ntawv ntawm 800-700-3874, ext. 5504 ib.
- Kev Pab Txhais Lus Xovtooj – muaj los pab rau cov tswvcuab teem sijhawm.
- Face-to-Face Interpreter Services - tuaj yeem thov rau lub sijhawm teem nrog tus tswv cuab.
- Yog xav paub ntxiv txog Kev Pabcuam Kab lis kev cai thiab hais lus, hu rau Alliance Health Education Line ntawm 800-700-3874, ext. 5580 lossis email rau peb ntawm [email protected].
Alliance Enhanced Care Management (ECM) thiab Kev Txhawb Zej Zog.
- Xa mus rau Alliance cov tswv cuab los ntawm Alliance Provider Portal, email ([email protected], xa ntawv lossis fax, lossis hauv xov tooj ntawm 831-430-5512.
- Rau Kev Tswj Xyuas Kev Kho Mob thiab Kev Saib Xyuas Kev Kho Mob, hu rau Pab Pawg Saib Xyuas Kev Kho Mob ntawm 800-700-3874 (TTY: Dial 711).
Alliance Health Education and Disease Management Programs – Daim Ntawv Qhia Txog Kev Noj Qab Haus Huv. Yog muaj lus nug, thov hu rau Alliance Health Education Line ntawm (800) 700-3874, ext. 5580 ua.
Alliance Transportation Services rau cov neeg mob uas muaj teeb meem kev thauj mus los.
- Kev thauj mus los tsis yog xwm txheej ceev (NEMT), hu rau 800-700-3874, ext. 5640 (TTY: Dial 711).
- Kev thauj mus los tsis yog kho mob (NMT), hu rau 800-700-3874, ext. 5577 (TTY: Dial 711).
Carelon Behavioral Health Provider Primary Care (PCP) Daim ntawv xa mus.

Tswj Kev Kho Mob

Daim Ntawv Qhia Tag Nrho-Cause Readmissions Tip Sheet

Tau txais kev pab

Kev Pabcuam Tswvcuab

Lub Alliance

Cov cuab yeej siv tau yooj yim