The Population Health and Care Transitions domain distinguishes responsibilities across organizational, leadership, and clinician levels. At the clinician level, quality improvement opportunities focus on direct patient care activities that influence safe transitions across settings.
Facilitating outpatient follow-up planning ensures continuity of care, medication reconciliation, patient understanding of discharge instructions, and timely post-discharge appointments—all critical factors in preventing readmissions. NAHQ emphasizes clinician accountability for coordinating care at transition points, particularly from inpatient to outpatient settings.
Sponsoring projects (Option A) and dedicating resources (Option B) are leadership or organizational responsibilities. Identifying barriers for an unfunded homeless patient (Option D) is important but typically falls under case management and social services rather than clinician-driven quality improvement. Therefore, Option C best reflects a clinician-level care transition improvement opportunity.
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