Clinical protocolStanding orders, risk stratification forms and hospital transition protocols

  • Clinical protocol

    Risk Stratification using a modified LACE Tool

    See how one LEAP site, Penobscot Community Health Care (PCHC), risk stratifies patients to direct the level of services needed for patient with complex health conditions. The highest risk patients are admitted to a robust complex care management program, then assessed using the modified LACE tool. PCHC developed a workflow involving the MA Health Coach, RN Care Manager, and social worker who are part of the complex care management team.

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  • Clinical protocol

    Hospital Pre-Discharge Virtual Patient Interview Protocol

    Learn how one LEAP site connects with patients while still in the hospital, to begin coordinating the transition. West County Health Centers uses technology to facilitate a more personal connection when possible.

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  • Clinical protocol

    Care management discharge criteria

    Learn about the criteria that one LEAP site uses to discharge patients from care management, once they have reached their clinical goals.

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  • Clinical protocol

    Hospital Transition Intake

    See protocol used by nurse care managers at one LEAP site during a transition follow-up after patients are discharged from the hospital.

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  • Clinical protocol

    Transition Care Clinical Protocol

    See protocol used by nurse care managers at one LEAP site for patient care transitions.

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  • Clinical protocol

    RN ER Case Management Clinical Protocol

    See protocol used by nurse care managers at one LEAP site to follow-up after patients have an ER visit.

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  • Clinical protocol

    Complex Care Management Intake Clinical Protocol

    See protocol used by nurse care managers at one LEAP site when patients are admitted into the high-risk case management program.

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  • Clinical protocol

    RN Complex Care Management Case Conference Clinical Protocol

    See protocol used by nurse care managers at one LEAP site to conduct a multidisciplinary case conference review of patients in the complex care management program who need a new or revised care plan. The Nurse care manager invites relevant clinical experts, which includes the provider, MA, behavioral health specialist, or pharmacist, depending on the cases being discussed.

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