Daim Ntawv Qhia Tag Nrho-Cause Readmissions Tip Sheet

Cov kev txhawb zog raug them rau tus kws kho mob txuas nrog (PCP) txhua xyoo, tom qab lub quarter thib plaub kawg. Yog xav paub ntxiv, saib mus rau lub CBI Technical Specifications.

• Cov tswv cuab tswj hwm nyob rau hnub Index Discharge Date.
• Dual kev pab them nqi cov tswv cuab.
• Cov tswv cuab hauv kev saib xyuas thaum kawg ntawm lub neej, tau txais cov kev pabcuam thaum kawg ntawm lub neej lossis cov uas tau tuag thaum lub xyoo ntsuas.
• Kev pw hauv tsev kho mob ceev nrog ib yam ntawm cov hauv qab no ntawm daim ntawv thov tso tawm:
  • Ib qho kev kuaj mob tseem ceeb ntawm cev xeeb tub lossis mob perinatal.
  • Ib qho kev npaj nyob hauv tsev kho mob siv ib yam 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 cov hlwb (lub raum, pob txha, cov hlwb thiab kev qhia txog cov hlwb pancreatic autologous).
    • Tej zaum yuav muaj cov txheej txheem npaj tseg yam tsis muaj kev kuaj mob tseem ceeb. Piv txwv li, kev phais hla cov hlab ntsha hauv lub plawv (coronary artery bypass), kev ntws dej ntawm sab ceg sab saud thiab kev sib koom ua ke ntawm cov pob qij txha lumbosacral yam tsis muaj kev kuaj mob tseem ceeb.
• Nyob hauv tsev kho mob uas hnub nkag mus kho mob yog tib yam li hnub tawm hauv tsev kho mob.

Cov ntaub ntawv rau qhov ntsuas no yog sau los ntawm kev thov.

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.¹

Cov ntaub ntawv los ntawm Lub Chaw Haujlwm Saib Xyuas Kev Tshawb Fawb thiab Kev Zoo ntawm Kev Kho Mob qhia tau tias cov neeg mob dub thiab Hispanic muaj feem ntau dua ntawm kev rov qab mus kho mob dua li cov neeg mob dawb. Muaj ntau yam uas ua rau muaj kev tsis sib xws ntawm kev rov qab mus kho mob dua, 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.²

[1] Dawb, MD, B., Carney, PhD, P., Flynn, MD, J., Fields, MD, MHA, S., & Chav Haujlwm Saib Xyuas Tsev Neeg. (2014, Lub Ob Hlis). Txo kev rov qab mus pw hauv tsev kho mob los ntawm kev hloov pauv kev kho mob thawj zaug. JFP. Tau txais los ntawm https://www.mdedge.com/jfponline/article/80074/practice-management/reducing-hospital-readmissions-through-primary-care.

[2] https://essentialhospitals.org/wp-content/uploads/2016/01/OMH_Readmissions_Guide.pdf.

• 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. 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?

• 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.
• 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 saib xyuas neeg mob hauv tsev kho mob kom coj lawv tuaj rau kev mus ntsib tom qab. Qhov no tuaj yeem ua tiav los ntawm kev mus ntsib kws kho mob hauv xov tooj thiab suav rau qhov kev ntsuas CBI Tom Qab Tawm Tsev Kho Mob. Qee lub tsev kho mob tau ua tiav qhov tseem ceeb ntawm kev teem sijhawm rau kev mus ntsib tom qab. Kev mus ntsib tom qab tawm tsev kho mob los ntawm kev hu xov tooj tau ua pov thawj tias muaj txiaj ntsig zoo ib yam li kev mus ntsib tus kheej thiab tuaj yeem tsim nyog dua.³
  • Siv qhov kev mus ntsib tom qab los qhia tus neeg mob txog nws tus mob thiab cov tshuaj, thiab ntsuam xyuas qib kev nkag siab ntawm tus neeg mob txog txoj kev npaj tawm mus thiab cov tshuaj. Cov txheej txheem ua tiav suav nrog kev siv 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 txog txoj kev npaj kho mob thiab xyuas nrog tus tswv cuab. Kev hu xov tooj tom qab tawm hauv tsev kho mob tau pom tias yuav txo tau kev rov qab mus pw hauv tsev kho mob thiab muaj txiaj ntsig zoo tshaj plaws ze rau hnub tawm hauv tsev kho mob.
  • 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.
  • Siv cov chaw kho mob tom qab tawm hauv tsev kho mob rau txoj hauv kev tshiab los txhim kho kev hloov pauv ntawm kev saib xyuas thiab txo cov nqi rov qab mus kho mob.

[3] Areeba Zain, Derek Baughman, Abdul Waheed. Tus nqi rov qab mus pw hauv tsev kho mob rau cov neeg mob uas tau txais kev saib xyuas tus kheej piv rau Telemedicine tom qab tawm hauv tsev kho mob. JABFM Lub Peb Hlis 2024, 37 (2) 166-171; Tau txais los ntawm https://www.jabfm.org/content/37/2/166.abstract.

• Alliance Cultural thiab Linguistic Services muaj rau cov neeg muab kev pabcuam network.
  • Cov Kev Pab Txog Lus - Thov cov ntaub ntawv ntawm 800-700-3874, ext. 5504.
  • Kev Pab Txhais Lus Hauv Xov Tooj - Hu ncaj qha rau tus neeg txhais lus hauv xov tooj 24 teev hauv ib hnub, 7 hnub hauv ib lub lim tiam.
  • Kev Pab Txhais Lus - Thov tau rau lub sijhawm teem tseg nrog tus tswv cuab.
  • Kev Pabcuam Txhais Lus Nyob Deb (VRI) - Thaum tus neeg txhais lus ntawm tus kheej tsis muaj lossis tsis yooj yim rau kev nkag mus.
  • 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 tias koj muaj lus nug dab tsi, thov hu rau Alliance Health Education Line ntawm 800-700-3874, ext. 5580.
• Alliance Transportation Services rau cov neeg mob uas muaj teeb meem kev thauj mus los.
  • Yog xav tau kev pab thauj neeg mob uas tsis yog xwm txheej ceev (NEMT), hu rau 800-700-3874, ext. 5640 (TTY: Hu 711).
  • Yog xav tau kev pab thauj mus los uas tsis yog kev kho mob (NMT), hu rau 800-700-3874, ext. 5577 (TTY: Hu 711).
• Siv Cov Cuab Yeej Qhia Rov Qab! Ib Txwm - Lub Koom Haum rau Kev Txhim Kho Kev Kho Mob.
• Daim Ntawv Qhia Txog Tus Cwj Pwm Kev Noj Qab Haus Huv Tus Cwj Pwm (PCP).
• Phau Ntawv Qhia Txog Kev Txhim Kho Kev Nyab Xeeb ntawm Tus Neeg Mob hauv Chaw Kho Mob Qib Pib los ntawm Kev Koom Tes nrog Cov Neeg Mob thiab Tsev Neeg – Lub Chaw Haujlwm Saib Xyuas Kev Tshawb Fawb thiab Kev Zoo ntawm Kev Kho Mob.