Playbook

Transitions for High‑Risk Patients: Discharge Bundle & Community Handoff (Playbook + Interactive Checklist)

A practical, operational playbook and interactive discharge checklist for patients with complex clinical and social needs. Includes a risk-screening flow, an enhanced discharge checklist with teach-back and medication reconciliation fields, warm-handoff script templates, configurable referral templates (SNF/home health), a 48–72 hour follow-up workflow, KPI targets, escalation triggers, role responsibilities, and saved-response capability for tracking completion and improvement.

Interactive Tool

Transitions for High‑Risk Patients: Discharge Bundle & Community Handoff

Purpose

This playbook helps teams reliably discharge patients with complex medical and social needs by combining a brief risk-screening, an enhanced discharge checklist, warm-handoff scripts for community providers, standardized referral templates, and an early follow-up workflow. Use this interactive tool at the point of discharge to document decisions, create follow-up tasks, and capture data for KPIs.

How to use

Complete the risk screen. Work through the checklist items with the patient and caregiver (use teach-back). Use the warm-handoff script to contact the receiving provider. Select and complete the referral template. Schedule the 48–72 hour follow-up call and record completion. Enter any escalations so care coordination can act.

Enter the unique patient ID or medical record number.
First and last name.
YYYY-MM-DD HH:MM (local timezone)
Select the primary high-risk category for this discharge.
Work through each item with the patient/caregiver and verify completion.
List key medication changes, tapered/stopped drugs, high‑risk meds, and patient understanding (use teach‑back summary).
Capture a short patient/caregiver statement that demonstrates understanding (example: 'I will take X at breakfast and call clinic if...').
Select yes to initiate immediate contact (phone/secure message) with post‑acute or community provider.
Choose how the warm handoff will be performed.
Use or adapt this script when contacting the receiving clinician or agency. Example: 'Hello, this is [Name], case manager from [Hospital]. I'm calling about [Patient], DOB [xx/xx/xxxx], being discharged today with diagnoses [list]. Key issues: medication changes [list], home oxygen [yes/no], wound care [yes/no]. Expected needs: home health SN, PT, medication delivery. We recommend follow‑up within 48–72 hours. Contact number: [phone].'
Summarize reason for referral, key clinical details, equipment needs, payer/care plan notes, and preferred start timing.
Choose a target for the first post‑discharge contact.
Name and role (case manager, nurse navigator, clinic RN).
Mark yes when call/visit completed.
Select the primary outcome from the early follow‑up contact.
If yes, capture the reason and notify supervising clinician/care team.
Describe symptoms, vitals if known, actions taken, and who was notified.
Enter organizational target (example: 90).
Enter organizational target (example: 95).
Name and contact information (phone/email).
List food assistance, transport services, caregiver respite, and behavioral health resources relevant to this patient.
Document any operational barriers, insurance/authorization steps, or pending tasks.
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