Protocol
Care team: transitions and hospitalizations
Description
Identify patients in need of care team engagement regarding transitions in care
Contributors
Duo Health
Last modified
January 8, 2024
Clinical notes
Denominator: Any patient who has not had an annual assessment ever and has a “transition task” (which will always be assigned to someone other than the engagement team). Numerator: Any patient in the denominator who has activity today (note or call or chart review)