As noted in Advance Health’s whitepaper , the post hospital assessment within our Readmission Prevention Program (RPP) evaluates the patient’s understanding regarding the recent hospitalization, discharge plan, follow-up care, and symptom recognition. It also evaluates the discharge plan, closes gaps when necessary and educates the member using “teach back” methods. The Nurse Practitioner makes certain that the patient has an appropriate, timely follow-up appointment and transportation. If there are barriers that prevent the patient from obtaining proper follow-up care, the nurse practitioner helps coordinate resources to bridge those gaps. The assessment provides insight into the patient’s understanding of her after-care and the goals of the follow-up visit. In addition, the patient’s support structure and, specifically, the caregivers’ health literacy, ability to recognize the patient’s symptoms and follow the care plan is evaluated and education is provided.