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...Case study transition of care for complex patient answer key v directions read the toc below following review each question and take a few minutes to write down your response tips think about elements action steps health team members conduct evidence based interventions included keep in mind primary practice specialist s clinical community linkages that may exist or new ones be beneficial family you morning admission discharge transfer adt list mr lawson is year old male on who was just discharged from hospital an exacerbation congestive obstructive pulmonary disease copd extreme fatigue have access ehr his most recent providers including pulmonologist physician per office protocol schedule phone call background has history smoking uncontrolled htn during hospitalization routine chest x ray revealed large mass left lower lung he with home oxygen prescriptions oncology consult pcp visit notes reveal retired lives at wife does not work suffers her own needs stated last receives monthly s...