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All About Hospice: Enrollment, IDT and Transitions of Care
At present transition of care between settings for patients can vary based on a variety of circumstances surrounding disease
progression, response to interventions, symptom crisis, and preexisting psychosocial stressors. Due to these potentially complex dynamics and the difficulty in identifying them early, patient care can suffer as problems may be left unassessed and may further undesired outcomes. The standard approach for meeting patient needs in transition of care between settings becomes more transdisciplinary, where acuity is assessed by numerous professionals trained to identify unique and interconnected needs in patients, and when possible before crisis occurs. Using a case-based approach, learner’s will follow an ALS patient from palliative care through end of life with hospice. This activity highlights the complexities of this patient population and eligibility relating to services, as well as addressing the physical, psychosocial, and spiritual complexities of serious illness care. Strategies facilitating effective care transitions between settings and between teams will be addressed.
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