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The period immediately after discharge is a vulnerable time for patients in which rapid changes can occur. Following up with patients and home caregivers soon after discharge can decrease confusion and reinforce follow-up plans. The National Transitions of Care Coalition encourages use of a standardized universal transfer tool to promote transfer of necessary patient information during care transitions. The Reducing Avoidable Readmissions Effectively Campaign provides transition information templates in its Safe Transitions of Care Toolkit, which includes checklists for important patient information.
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