Internal Workflow for Hospital Transition Outreach
Internal procedure for post-discharge outreach and escalation.
Purpose
Use this workflow to coordinate timely outreach after an inpatient or post-acute event.
- Validate the event and risk indicators.
- Review existing care plan and provider contacts.
- Attempt outreach using approved channels and document each attempt.
- Confirm medications, follow-up, transportation, and social needs.
- Escalate unresolved clinical or safety concerns to the supervisor.
Document only the minimum necessary information in approved systems.