3 main areas areas for focus questions

Trudy and I were discussing the questions' focus. I summarized where we got to here.

Patient & Family

What does the patient need to know specifically at this time?
Remember patients may have other challenges
What HC members can you access to assist you at this time?

Healthcare Teams

Education to patient, assessing what they are ready for ( depression, receptiveness, anxiety, level of self help) , barriers to follow up, how to involve patient

Transitions Perspective 

Help patients take responsibility.  Continuity of patient information from HC professional to healthcare professional. Discharge plan. Continuity of care: supportive of communicating  discharge plan to the next transition point.
What tools can we put in place to support Continuity of Care ( Discharge plan)?