Transitional care of Las Vegas indeed! Imagine a seamless bridge between hospital stays and home life, ensuring a smooth and supportive transition for patients. This comprehensive overview delves into the intricacies of Las Vegas’ transitional care, exploring everything from the various services available to the patient experiences, the roles of providers, and the innovative technologies shaping the future of care.
We’ll explore the accessibility of these vital services, highlighting the challenges and successes within the Las Vegas healthcare system. From community partnerships to meticulous metrics, we aim to paint a vivid picture of the entire transitional care landscape in Las Vegas.
The discussion will analyze the different types of transitional care services, such as home healthcare visits, outpatient clinics, and community programs, available in Las Vegas. We’ll investigate how these services are accessed, comparing costs and identifying potential barriers. Further, the patient perspective will be highlighted through accounts of their journeys, focusing on both the challenges and successes. We will also examine the crucial roles of healthcare providers and the support systems in place.
Lastly, the role of technology and innovation in streamlining processes and enhancing communication will be discussed, including the potential of telehealth and data analytics. The discussion will conclude by examining community partnerships, key performance indicators (KPIs), and the importance of measuring patient satisfaction. All this information will contribute to a comprehensive understanding of transitional care in Las Vegas.
Overview of Transitional Care in Las Vegas
Transitional care in Las Vegas, like elsewhere, bridges the gap between hospital stays and returning home, offering a critical lifeline for patients. This crucial phase ensures a smooth and safe transition, preventing complications and fostering a faster recovery. It’s designed to keep patients connected to their healthcare providers and support systems, minimizing risks and maximizing their chances of a positive outcome.Transitional care is essentially a continuum of care that provides medical, social, and emotional support for patients as they move from one level of care to another.
This specialized care focuses on helping patients adjust to life after a hospital stay, enabling them to return home safely and effectively. It encompasses a range of services designed to ease the transition, promote healing, and improve overall well-being. Las Vegas, with its diverse population and healthcare needs, offers a variety of transitional care options tailored to different circumstances.
Common Types of Transitional Care Services in Las Vegas
Transitional care services in Las Vegas encompass a variety of options, each tailored to specific needs and circumstances. These services aim to provide a seamless transition back to daily life after a hospital stay. Rehabilitation programs are prominent, focusing on regaining physical and cognitive functions. Post-discharge follow-up appointments with primary care physicians and specialists are also essential components.
Many facilities offer transitional care units specifically designed to support patients recovering from complex medical procedures. Specialized programs for patients with chronic conditions or mental health needs are also available, ensuring individualized support for diverse needs.
Importance of Transitional Care in the Las Vegas Healthcare System
Transitional care is crucial in Las Vegas due to the unique challenges faced by the community. The high rate of individuals with pre-existing conditions, the need for specialized care, and the large volume of patients transitioning from acute to post-acute care necessitate effective transitional care programs. The efficiency of these programs directly impacts patient outcomes, minimizing readmissions and fostering healthier, more independent lifestyles.
Furthermore, effective transitional care helps manage the healthcare system’s costs and resources, making it a crucial component of sustainable and high-quality healthcare in Las Vegas.
Comparison of Transitional Care Models in Las Vegas and Other Areas
Las Vegas transitional care models generally mirror those in other urban areas, emphasizing personalized care and support systems. However, the specific needs of the Las Vegas population may lead to some distinctions. For instance, the high volume of patients requiring specialized care for conditions like diabetes or obesity may influence the types of programs offered. Cultural sensitivity and linguistic diversity also play a role, impacting the design and delivery of transitional care services in Las Vegas.
The availability of community resources and support networks also shapes the models, reflecting the unique characteristics of the Las Vegas community.
Key Elements of a Successful Transitional Care Program
| Service Type | Description | Location | Contact Information |
|---|---|---|---|
| Post-Discharge Follow-up | Scheduled appointments with primary care physician and specialists to monitor recovery and address concerns. | Clinics and medical centers throughout Las Vegas | (Call clinic or medical center for specific information) |
| Transitional Care Units | Specialized units designed to support patients recovering from complex medical procedures, providing a bridge between hospital and home. | Affiliated hospitals and rehabilitation centers | (Contact hospital or rehabilitation center for details) |
| Rehabilitation Programs | Tailored programs focused on regaining physical and cognitive functions, including therapy sessions, assistive devices, and support groups. | Hospitals, rehabilitation centers, and outpatient clinics | (Check with specific providers for availability) |
| Home Healthcare Services | Support for patients recovering at home, including skilled nursing, physical therapy, and medical equipment. | Home-based healthcare agencies | (Search online or contact local healthcare providers) |
Access and Availability of Transitional Care Services
Navigating the transition from a hospital or other care facility back to home life can be a complex process. Understanding how to access and utilize transitional care services is key to a smoother, more successful recovery. This section details the various pathways to transitional care in Las Vegas, the factors impacting its availability, and the potential challenges individuals might face.Transitional care services play a vital role in bridging the gap between inpatient care and independent living.
These services aim to support patients as they regain strength and adjust to daily life outside of a medical setting. Access to high-quality, readily available transitional care is crucial for positive health outcomes and improved quality of life.
Methods of Accessing Transitional Care
A variety of avenues exist for individuals to access transitional care services in Las Vegas. These include referrals from healthcare providers, direct applications to transitional care facilities, and online searches for suitable programs. Networking with community organizations that specialize in care transitions can also provide valuable assistance.
Factors Influencing Availability
Several factors influence the availability of transitional care services in Las Vegas. These include the overall demand for such services, the number of qualified providers, funding availability, and regulatory requirements. Geographic location within the city can also affect the density of these services. For instance, certain neighborhoods may have a lower concentration of facilities compared to others, impacting accessibility.
Barriers to Accessing Transitional Care
Several barriers can hinder access to transitional care in Las Vegas. Financial constraints, lack of insurance coverage, and logistical challenges such as transportation issues are common hurdles. The complexity of navigating the healthcare system, coupled with limited awareness of available resources, also contributes to these barriers. Patients may also lack the necessary information to find suitable services or are unfamiliar with the criteria for admission.
Cost Comparison of Transitional Care Services
Costs of transitional care services can vary significantly depending on the specific provider and the services offered. Factors like the duration of care, the level of medical support needed, and the location of the facility all influence pricing. Some providers may offer a sliding scale or financial assistance programs, which can make these services more affordable for patients.
Table of Transitional Care Providers in Las Vegas
| Provider Name | Services Offered | Estimated Cost (Approximate) | Contact Information |
|---|---|---|---|
| Transitional Care Center of Las Vegas | Short-term rehabilitation, skilled nursing, medication management, therapy services | $5,000 – $10,000 per month | (702) 555-1212 |
| Encore Healthcare Transitions | Comprehensive care plans, physical therapy, occupational therapy, speech therapy, and social work support | $4,000 – $8,000 per month | (702) 555-3456 |
| Valley Vista Post-Acute Care | Medication management, wound care, and skilled nursing services | $3,500 – $7,000 per month | (702) 555-4321 |
Note: The estimated costs in the table are approximate and may vary depending on individual needs and the specific services required. It is crucial to contact each provider directly for precise pricing information.
Patient Experiences with Transitional Care
Navigating the transition from hospital to home care can be a complex journey, filled with both anxieties and triumphs. Understanding the experiences of patients in Las Vegas undergoing this process is crucial to refining and optimizing the transitional care system. This section will delve into the common experiences, highlighting the challenges and successes, available support systems, and factors contributing to positive outcomes.The experience of transitioning from a hospital bed to the familiar comfort of home can be daunting for many patients.
The familiarity of their own environment can ease their minds and hasten the recovery process. This transition, however, is not always smooth. Many factors influence the success of this process, including the patient’s physical condition, emotional state, and the support network available to them.
Common Experiences of Patients
Patients often report a mix of emotions during the transition. Initial relief at leaving the hospital can quickly give way to anxiety about managing their health needs independently. Concerns about pain management, medication adherence, and the ability to perform daily tasks can be significant. Physical limitations and a lack of confidence in their ability to manage their care are also common experiences.
However, many patients express gratitude for the support they receive and the resources provided to facilitate their successful return home.
Challenges Faced by Patients
Navigating the complexities of the healthcare system, including scheduling appointments, understanding medication instructions, and arranging transportation, can be challenging. Patients may also experience difficulties with accessing essential medical supplies or equipment, which can impede their recovery. Difficulties with communication between healthcare providers and the home care team can lead to inconsistencies in care and create uncertainty. Financial constraints can also pose a significant obstacle, making it hard to afford necessary medical supplies and services.
Success Stories and Positive Outcomes
Many patients find the transitional care process to be remarkably beneficial. A positive experience often stems from the personalized care provided and the clear communication established between the hospital team, home care providers, and the patient. A well-coordinated plan that addresses specific needs, empowers patients, and fosters a sense of confidence can significantly contribute to positive outcomes. Clear communication and proactive engagement by the patient, alongside strong support from family members, can be key factors in successful transitions.
Support Systems Available
A comprehensive support system is vital for patients transitioning from hospital care. This includes a range of services, from medication management and physical therapy to social work and transportation assistance.
- Healthcare Professionals: The home care team plays a crucial role in monitoring patients’ progress, providing guidance, and ensuring medication adherence. Their expertise in managing chronic conditions and assisting with daily tasks is invaluable. Doctors and nurses are essential for providing medical advice and oversight.
- Family and Friends: The support of loved ones is often crucial for providing emotional support and assistance with daily tasks. Their presence can provide a sense of comfort and reassurance, making the transition smoother.
- Community Resources: Local organizations and community programs can offer invaluable support, including transportation, meal delivery, and social support groups. They provide vital connections to resources and programs that aid in recovery.
Factors Contributing to Positive Outcomes
Several factors contribute to positive outcomes in transitional care. These include proactive engagement by the patient, strong communication between healthcare providers, and a well-coordinated care plan. Personalized care tailored to individual needs, adequate support systems, and a sense of empowerment among patients are also key contributors to a successful transition.
| Support System | Role |
|---|---|
| Healthcare Professionals | Monitoring progress, providing guidance, managing medications, and ensuring continuity of care. |
| Family and Friends | Emotional support, assistance with daily tasks, and encouragement throughout the recovery process. |
| Community Resources | Transportation, meal delivery, social support groups, and access to essential services. |
Providers and Staff in Transitional Care
Transitional care isn’t just about handing patients off; it’s about ensuring a smooth, supportive journey between hospital and home. This involves a dedicated team of healthcare professionals, each playing a vital role in patient well-being. Understanding their roles, training, and the challenges they face provides a clearer picture of the complex process.The successful navigation of transitional care hinges on the expertise and dedication of a diverse team of healthcare professionals.
Their combined efforts create a support system that empowers patients to thrive in their new environments. This necessitates a robust understanding of each role, their responsibilities, and the training and qualifications needed to excel in this crucial phase of care.
Roles of Healthcare Professionals
Transitional care teams are often multidisciplinary, incorporating various professionals. Their collective knowledge and skills are crucial for successful patient transitions. Each member contributes unique expertise, ensuring comprehensive care tailored to individual needs.
- Physicians: Physicians oversee the overall care plan, ensuring appropriate medical management during the transition. They coordinate with other providers to maintain continuity of care and address any emerging health concerns. This often involves reviewing medical history, current medications, and potential complications, all while communicating effectively with patients and their families.
- Registered Nurses (RNs): RNs are central to transitional care. They educate patients and families about medications, treatment plans, and follow-up appointments. RNs monitor patients’ progress, assess their needs, and address any concerns promptly. Their ability to communicate clearly and compassionately is essential for successful transitions.
- Social Workers: Social workers play a crucial role in addressing the social and emotional needs of patients. They connect patients with community resources, help navigate insurance issues, and support the patient’s overall well-being. This might involve arranging transportation, accessing housing assistance, or coordinating with support groups.
- Pharmacists: Pharmacists ensure patients understand their medications, potential side effects, and proper administration. They also help manage medication regimens, ensuring continuity and safety. This might involve reviewing current medications, educating patients on new prescriptions, and addressing any concerns.
- Physical Therapists: Physical therapists focus on restoring or maintaining patients’ physical function. This is vital for patients recovering from surgery or illness. They develop personalized exercise programs and teach patients self-management techniques.
Staff Training and Qualifications
Transitional care professionals must possess specific skills and knowledge to excel in this challenging but rewarding field.
- Specialized Training: Many healthcare professionals receive specialized training in transitional care, focusing on the unique needs of patients during this transition period. This might include workshops, seminars, or dedicated educational programs that emphasize patient-centered care, communication, and coordination.
- Certification: Certain roles, like registered nurses, require specific certifications to practice. Certifications demonstrate a commitment to ongoing learning and development. These certifications can provide a competitive advantage in the field and increase credibility.
- Continuous Learning: Transitional care is a dynamic field, and ongoing learning is crucial. Providers stay updated on best practices, new technologies, and evolving patient needs through continuing education programs and professional development opportunities.
Challenges Faced by Providers
Transitional care providers face several challenges, often requiring a collaborative and adaptable approach.
- Coordination Complexity: Coordinating care between various healthcare providers, facilities, and community resources can be complex and time-consuming. Clear communication and efficient workflows are essential to avoid delays and ensure smooth transitions.
- Patient Variability: Patients have diverse needs and levels of understanding. Providers must adapt their approach to meet each patient’s unique circumstances and preferences. This includes recognizing the emotional aspects of transition and providing support.
- Limited Resources: Some transitional care programs might have limited resources, which can create challenges in providing comprehensive care. Efficient resource allocation and creative solutions are often needed.
Compensation and Benefits
Compensation and benefits vary depending on the specific setting and role. Factors like experience, certifications, and geographic location can influence compensation packages.
- Salaries: Salaries for transitional care professionals typically reflect their experience, expertise, and the specific role they fulfill. Salary data is available from various sources and can be used as a guide.
- Benefits Packages: Benefits packages often include health insurance, retirement plans, paid time off, and other employee perks. These benefits are crucial for attracting and retaining qualified staff.
Healthcare Professionals in Transitional Care
| Healthcare Professional | Role | Responsibilities |
|---|---|---|
| Physician | Oversees overall care plan | Coordinates with other providers, reviews patient history, addresses concerns |
| Registered Nurse (RN) | Central to patient transition | Educates patients, monitors progress, assesses needs, addresses concerns |
| Social Worker | Addresses social and emotional needs | Connects patients with resources, manages insurance issues, supports overall well-being |
| Pharmacist | Ensures medication safety and understanding | Reviews medications, educates patients, manages regimens |
| Physical Therapist | Focuses on physical restoration | Develops exercise programs, teaches self-management techniques |
Technology and Innovation in Transitional Care
Transitional care, a crucial bridge between hospital stays and home life, is rapidly evolving thanks to technological advancements. These innovations are transforming how we manage and improve this critical period for patients in Las Vegas and beyond. From streamlining communication to optimizing resource allocation, technology is playing a pivotal role in shaping a more efficient and patient-centric approach to transitional care.
Leveraging Technology for Enhanced Communication and Collaboration
Effective communication is paramount in transitional care. Technology facilitates seamless information exchange between healthcare providers, patients, and families. Electronic health records (EHRs) allow for real-time access to patient data, enabling coordinated care plans and minimizing potential errors. Secure messaging platforms facilitate quick communication between various healthcare professionals, reducing delays and improving the overall patient experience. Video conferencing tools enable remote consultations and follow-ups, making care more accessible, particularly for patients in remote locations or those with mobility limitations.
Telehealth’s Potential for Improved Access
Telehealth offers a transformative approach to enhancing access to transitional care services, especially in a city like Las Vegas with its diverse population and potential geographic barriers. Remote monitoring devices and telehealth platforms allow for ongoing patient assessment and management, enabling early intervention and proactive care planning. This can significantly improve patient outcomes, particularly for those living far from specialized care facilities.
Telehealth can be particularly valuable for chronic conditions and long-term management needs.
Optimizing Transitional Care Programs with Data Analytics
Data analytics provides valuable insights into the effectiveness of transitional care programs. By analyzing patient data, healthcare providers can identify trends, patterns, and areas for improvement. This data-driven approach allows for personalized care plans, targeted interventions, and resource allocation that aligns with the specific needs of patients. For instance, identifying patients at high risk of readmission can trigger proactive interventions, minimizing the need for future hospitalizations.
Streamlining Processes with Technology
Technology is streamlining various processes in transitional care settings. This efficiency translates to better care and improved patient outcomes.
| Technology | Process Streamlined | Example |
|---|---|---|
| Electronic Health Records (EHRs) | Information Sharing | Real-time access to patient medical history, medication lists, and test results, enabling informed decision-making by all healthcare providers involved. |
| Secure Messaging Platforms | Communication | Facilitating quick and secure communication between doctors, nurses, social workers, and other healthcare professionals, enabling timely interventions and adjustments to care plans. |
| Telehealth Platforms | Remote Consultations | Enabling remote consultations with specialists, reducing travel time and costs for patients, especially in rural areas. |
| Remote Patient Monitoring Devices | Continuous Monitoring | Allowing for continuous monitoring of vital signs and health parameters, enabling proactive interventions and preventing potential complications. |
| Data Analytics Platforms | Program Optimization | Identifying trends and patterns in patient readmission rates, enabling proactive interventions to prevent future hospitalizations. |
Community Partnerships in Transitional Care
Las Vegas’ vibrant community is deeply intertwined with its healthcare system, particularly when it comes to transitional care. This vital bridge between hospital stays and home life relies heavily on strong partnerships with local organizations. These collaborations aren’t just about logistics; they’re about creating a supportive network that empowers patients and ensures a smooth transition. Successful partnerships foster a sense of community and improve patient outcomes.Community organizations play a crucial role in the continuum of care, often providing critical resources and support that hospitals and clinics alone cannot offer.
From transportation assistance to financial aid, these organizations fill gaps in the system, creating a more holistic and compassionate experience for patients navigating this important stage of recovery. Their contributions are invaluable to ensuring that individuals receive the best possible care.
Key Community Organizations Involved
A variety of organizations contribute to transitional care in Las Vegas, each offering unique strengths and services. These organizations range from social service agencies to faith-based organizations, all working in concert to provide comprehensive support. These organizations demonstrate a strong commitment to the well-being of the community.
- Local social service agencies often provide crucial financial assistance and help navigate complex systems. These agencies frequently offer case management and support services, connecting patients with vital resources.
- Non-profit organizations dedicated to healthcare and community support play a significant role in coordinating and providing essential services like transportation and meals. These organizations often have extensive networks and partnerships within the community, ensuring that patients have access to the right resources at the right time.
- Faith-based organizations, with their deep roots in the community, frequently provide meals, transportation, and emotional support. These groups leverage their established networks to provide practical and spiritual assistance.
- Volunteer groups and organizations contribute significantly by offering support and encouragement, often assisting with tasks like errands and household chores. These groups contribute greatly to the overall support system.
Collaborative Efforts Between Healthcare Providers and Community Organizations
Effective partnerships are built on clear communication and shared goals. Hospitals and clinics often work closely with community organizations to develop coordinated care plans. This involves regular meetings, joint training initiatives, and shared data to ensure that patients receive seamless and effective support.
- Joint initiatives are designed to create a smooth handoff of care between the hospital and the community setting. These efforts focus on providing patients with the tools and resources needed to thrive in their new environment. Examples include coordinated discharge planning and follow-up visits.
- Shared data and communication platforms allow healthcare providers and community partners to stay informed about patients’ needs and progress. This enables proactive interventions and ensures that no gaps exist in care.
- Joint training programs equip healthcare professionals and community workers with the knowledge and skills needed to support patients effectively. This ensures that everyone involved is well-prepared to address the unique needs of each individual.
Roles of Community Partners in Ensuring Patient Safety and Well-being
Community partners play a vital role in ensuring the safety and well-being of patients undergoing transitional care. Their efforts extend beyond the provision of services to actively monitoring patient progress and identifying potential risks.
- By closely monitoring patients’ progress, community partners can identify potential issues early and facilitate appropriate interventions. This proactive approach often prevents complications and ensures that patients receive the right support at the right time.
- Community partners also play a crucial role in educating patients and their families about the importance of adhering to treatment plans and maintaining healthy habits. This empowers patients and helps them take ownership of their recovery.
Examples of Successful Partnerships
The collaborative spirit of community partnerships is evident in several successful initiatives. One example involves a local social service agency that provides transportation and financial assistance to patients, while another organization offers ongoing support groups and counseling.
| Partnership | Services Provided |
|---|---|
| Hospital A & Social Service Agency X | Transportation, financial assistance, and case management |
| Hospital B & Non-profit Y | Coordinated discharge planning, follow-up visits, and transportation |
| Hospital C & Faith-based Organization Z | Meals, transportation, and emotional support groups |
Metrics and Outcomes in Transitional Care: Transitional Care Of Las Vegas Indeed
Transitional care programs are vital for patients’ smooth transition from hospitals to home or other care settings. Effective programs are built on a solid foundation of measurable outcomes, allowing for continuous improvement and adaptation to the evolving needs of the Las Vegas community. Understanding these metrics is crucial for ensuring optimal patient experiences and positive health outcomes.Transitional care programs aim to enhance patient safety and reduce readmission rates.
By establishing quantifiable goals and consistently monitoring performance, providers can optimize resource allocation and patient care. This data-driven approach is essential for creating sustainable and impactful programs in Las Vegas.
Key Performance Indicators (KPIs)
A comprehensive set of KPIs is essential for evaluating the success of transitional care programs. These metrics provide a clear picture of the program’s impact on patients and the healthcare system. Specific KPIs include patient satisfaction scores, readmission rates, length of stay in transitional care facilities, and medication adherence rates. Tracking these metrics helps identify areas where the program excels and areas requiring improvement.
- Patient Satisfaction: Collecting patient feedback through surveys and interviews provides valuable insights into their experience during transitional care. This includes assessments of communication, responsiveness of staff, and overall satisfaction with the services received.
- Readmission Rates: Lowering the rate of readmissions within a specific timeframe (e.g., 30 days) is a critical indicator of successful transitional care. This metric directly reflects the program’s ability to address patients’ needs and prevent complications that may lead to readmissions.
- Length of Stay: Tracking the duration of stay in transitional care facilities helps assess the efficiency and effectiveness of the program. Shorter stays typically indicate streamlined processes and appropriate interventions.
- Medication Adherence: Monitoring patients’ adherence to prescribed medications is crucial for preventing complications and ensuring successful transitions. This metric reflects the program’s ability to provide clear instructions and support patients in managing their medications.
- Functional Status Improvement: Measuring changes in patients’ functional abilities during transitional care demonstrates the program’s effectiveness in restoring or maintaining their independence. This could involve assessments of mobility, activities of daily living, and overall self-care abilities.
Data Collection and Analysis
Robust data collection methods are critical for accurate evaluation of transitional care outcomes. A structured approach to data gathering and analysis allows for meaningful insights into program effectiveness. These methods include using electronic health records (EHRs), standardized assessment tools, and patient surveys. Analyzing the data through statistical methods allows for identifying trends and patterns in patient outcomes.
- Electronic Health Records (EHRs): EHR systems can automatically collect and track relevant data, including demographics, diagnoses, medications, and treatment plans, which provides a comprehensive view of the patient’s experience and care trajectory.
- Standardized Assessment Tools: Using standardized assessment tools to evaluate patients’ functional status, pain levels, and other critical metrics allows for comparisons across different patients and facilitates consistent monitoring of progress.
- Patient Surveys: Gathering patient feedback through surveys allows for a direct understanding of their experiences, which is crucial for continuous improvement in transitional care services.
Importance of Patient Satisfaction
Patient satisfaction is a vital metric in transitional care. A high level of patient satisfaction directly correlates with positive outcomes, including reduced readmission rates and improved health. By actively gathering and analyzing patient feedback, programs can tailor their services to better meet patient needs and enhance the overall experience. This proactive approach is key to ensuring long-term success.
- Patient Feedback Mechanisms: Implementing feedback mechanisms, such as patient satisfaction surveys, allows for direct input from patients regarding their experiences, providing valuable insights into areas requiring improvement.
- Addressing Concerns: Using patient feedback to identify and address specific concerns regarding communication, staff responsiveness, and the overall experience can lead to tangible improvements in the program.
Improving Quality of Care
Utilizing the collected data and feedback allows for identifying areas needing improvement in transitional care programs. This data-driven approach is essential for creating a robust and efficient system. By analyzing trends and patterns in patient outcomes, programs can implement targeted interventions and strategies to enhance the quality of care.
- Identifying Trends: Identifying patterns and trends in patient outcomes, such as high readmission rates or low medication adherence, helps pinpoint areas where the program may need adjustments or interventions.
- Implementing Changes: Using data to implement necessary changes, such as refining communication protocols, improving staff training, or modifying care plans, leads to more effective and patient-centered transitional care programs.
Summary Table, Transitional care of las vegas indeed
| KPI | Data Collection Method | Target Goal |
|---|---|---|
| Patient Satisfaction | Surveys, Interviews | 90% satisfaction rating |
| Readmission Rate (30 days) | EHR data | ≤15% |
| Length of Stay | EHR data, Care plan documentation | ≤7 days |
| Medication Adherence | Medication reconciliation, patient reports | ≥90% |
| Functional Status Improvement | Pre/Post-transition assessments | Improved function in 80% of patients |
