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Transitions of Care Checklist: SNF to Home Health Care

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Skilled Nursing Care Transition Checklist Notes Date Completed SNF ensures a valid Face to Face (F2F) visit has been completed Provide HHA copies of discharge note and last note written by MD Provide patient/caregiver with Home Care agency's name and phone number for questions Discuss diagnosis specific red flags with patient/caregiver (e.g. CHF: shortness of breath, edema) Encourage patient to participate in care Encourage follow-up appointment with PCP after transition home SNF identify and set up delivery of DME and other essentials need SNF ensure patient has medications/prescriptions Transitions of Care Checklist: SNF to Home Health Care As networks continue to narrow it is vital to ensure smooth and safe transitions of care. Check out our top tips for Skilled Nursing and Home Health Care agencies.

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