Transition Intervention   Point of Discharge Interview Interview patient and/or family Establish current health status Establish Personal Health Record Acquire current medication list Assess disciplinary needs: PT, OT, SLP, RD, MSW, HHA Personal Health Record Includes specific patient Information: Personal Physician Advance directives Hospital Caregiver Intervention checklist Medication record Medical history Notes for Primary Care Physician Equipment needed or utilized Integrated Care services         Disease Specific Education Cardiopulmonary CVA Orthopedic Multiple Sclerosis Cognitive Diabetes PICC - IV therapy Wound Care Circulatory insufficiency Scheduling Follow-up - PCP Follow up appointment and communication with Primary Care Physician: Personal Health Record Contact to schedule appointment Prepare Personal Health Record for physician review Assess transportation needs, coordinate Physician communication Physician Communications