Table 1 Main checklists of PaTH
Time / responsible | Procedure (s) / main themes on checklists |
|---|---|
Discharge call from hospital to home care services at the day of discharge (Checklist 1). | Predefined information was transferred to home care services with emphasis on immediate follow-up needs and medication. |
Post-discharge assessments by a home care nurse within three days (Checklist 2). | Structured assessment with emphasis on health issues, preventive measures, self-care and safety issues. |
Post-discharge examination by the general practitioner (GP) within 2 weeks (Checklist 3). | Structured exchange of information between home care services and GPs before and after the GP consultation. Emphasis on observations passed on by the home care professionals, review of medical situation and medication by the GP, and plan for further follow up in collaboration between the GP and the home care services. |
Post-discharge assessment by a home care professional within 4 weeks (Checklist 4). | Structured assessment with emphasis on physical / cognitive functional ability, health issues, safety issues, social situation and self-care. Evaluation of whether care matches the needs of the care recipients. |