Part 1: Listen Review the HRET HIIN

Part 1: Listen Review the HRET HIIN Readmission whiteboard video series. https://www.aha.org/center/quality-safety Watch the Mrs. Smith Interview that is located below. As you watch the simulation, imagine that you are the PHN sitting across from Mrs. Smith on the adjacent recliner, listening as she shares her story with you. Let her talk. Just listen. Discover all the reasons why she is on the revolving door of re-hospitalization. https://youtu.be/jy4ecX9uiyA Is Mrs. Smith at low, moderate, or high risk of re-hospitalization? Explain. Is Mrs. Smith getting the support she needs as she transitions from hospital to her home? What chronic conditions predispose her to re-hospitalization? What post-discharge outreach might she need? Who could provide this to her? What additional resources might she need on an on-going basis to remain safely in her home? Who might be able to provide these needed resources for her? Take notes and make a list of issues that may have contributed to her revolving door re-hospitalizations Johns Hopkins IPE Event Patient Home Visit Simulation Part 2: Plan Review your notes and identify Mrs. Smith’s top three (3 )priority needs. Prioritize a plan by stating your each priority concern, and summarizing the action plan for each. (See format example below) Priority Concern #1: Action plan to address concerns. Priority Concern #2: Action plan to address concerns. Priority Concern #3: Action plan to address concerns. Utilize two references SCIENCE HEALTH SCIENCE NURSING RNRS 480

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