PDF《Sharing炉he烫are爋f?》

s?system? (three?or?more) ? Require?multiple?medications?and/or?home?care ? Are?technology\dependent?(G\tube,?ventilator,?and?tracheostomy ? At?risk?of?frequent?and?prolonged?hospitalizations Referrals ? May?be?made?by?Primary?Care?Providers,?subspecialists,?insurance?case? managers,?early?intervention?programs?and?self?referrals ? Must?communicate?with?PCP?prior?to?referral ? Family/patient?must?be?aware?of?the?nature?of?the?referral ? Evaluation?of?referral?will?be?made?to?determine?if?child?is?eligible?for?the? program ? Contact?Complex?Care:??202\476\4664 What?did?CCP?do?for?FG?? ? FG?was?referred?by?his?PCP?for?care?coordination ? At?each?care?coordination?visit: C Discussed?and?addressed?parent?concerns?and?care?needs C Reconciled?medications C Reviewed?subspecialty?recommendations C Discussed?goals?of?care C Developed?a?plan?of?care,?which?is?shared?with?the?PCP C Identified?new?community?resources/supports ? Between?care?coordination?visits: C Interim?medical?management? C Ongoing?communication?with?patient/family,?PCP,?subspecialists,? Parent?Navigator,?school?nurses,?and?other?members?of?care?team C Completion?of?nursing?and?equipment?orders C Medication?reconciliation?and?refills June?3,?2015 Pediatric?Perioperative?Care June?3,?2015 Risk?to? Patient Risk?of? Anesthesia Risk?of?the? Procedure Pre\operative?Care?Clinic?(POCC) ? Provide?comprehensive?assessment?of? perioperative?risks?for?patients?with?medical? complexity?and?provide?specific?medical? recommendations ? Gather?a?detailed?medical?history?and?physical?exam? with?a?focus?on?identifying?potential?pre\ and?post\ operative?risk?factors?(Risk?to?the?Patient) ? Coordinate?care?with?amongst?various?specialists? including?the?Surgeon?(Risk?of?the?Procedure) ? Evaluate?patient?in?conjunction?with?an?Anesthesiologist? (Risk?of?Anesthesia) ? Assist?in?management?of?Postoperative?Care?of????? surgical?patients?that?were?identified?in?POCC Pre\operative?Care?Clinic?(POCC) Hospitalist?develops? perioperative?plan Contacts? subspecialists?to?add? recommendations Discusses?plan?with? surgeon Integrates? recommendations? and?provides? comprehe........