Collaborate with hospital’s quality and case management departments, if applicable, to:
- Measure readmission rates for patients you treat in the hospital
- Evaluate discharge program and follow up process specific to your patients
- Review discharge teaching to patients/family members
- Literacy level, patient activation level, pictures, use of teach-back
- When to call who for what (to minimize use of emergency room or need for rehospitalization)
- Identify community support available to patient