Method and system for the transitional care of congestive heart failure patients

摘要

A method for the transitional care of patients, including but not limited to congestive heart failure patients, includes the step of conducting a hospital consultation prior to a discharge from an extended hospital stay. When a patient is identified as being a proper candidate for a transitional care facility, the patient is discharged to the transitional care facility. At the transitional care facility, the patient is repeatedly educated regarding topics selected from the group of warning signs, medication, diet and exercise. The patient is tested for a level knowledge regarding the one or more topics. A transitional care facility consultation is conducted to determine whether the patient is a proper candidate for discharge to home care. In such event, the patient is discharged to home care and a summary is generated to a referring physician of the patient regarding a recommendation for continued care.