care-transition-coordination

# Care Transition Coordination Manage care transitions between settings including discharge planning, medication reconciliation, follow-up scheduling, and post-acute care coordination. ## Overview This skill enables effective coordination of care transitions across healthcare settings. It encompasses discharge planning, medication reconciliation, follow-up coordination, and communication to ensure safe and effective care continuity. ## Capabilities ### Discharge Planning - Assess patient needs - Coordinate services - Arrange equipment - Plan follow-up care - Educate patients/families ### Medication Reconciliation - Review medication lists - Identify discrepancies - Resolve conflicts - Update records - Educate patients ### Follow-Up Coordination - Schedule appointments - Arrange transportation - Coordinate referrals - Track completion - Manage barriers ### Post-Acute Coordination - Assess placement needs - Coordinate with facilities - Transfer information - Monitor transitions - Address issues ## Usage Guidelines ### Transition Process 1. Identify transition needs early 2. Assess patient/family situation 3. Develop transition plan 4. Coordinate necessary services 5. Reconcile medications 6. Provide education 7. Execute transition 8. Follow up ### Communication Standards - Timely information transfer - Complete documentation - Clear handoff communication - Patient education materials - Provider notifications ### Risk Mitigation - Identify high-risk patients - Addres...