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Care Coordination Best-Practices Toolkit

Care Coordination Best-Practices Toolkit

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• No advance directive or planning beyond do-not-resuscitate status. • Assuming the patient is the key learner and not including the family or a caregiver. • Not reinforcing the need to make and keep a follow-up appointment and/or not scheduling a follow-up appointment for the patient.

  Directive, Advance, Advance directive

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