community partners transitions in care update 2014 q1
TRANSCRIPT
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COMMUNITY PARTNERSTRANSITIONS IN CARE UPDATE2014 Q1
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Project Outline
Open lines of communication Variations in Requirements for
Facilities Loop closure:
Physician input for patient care
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Project Outline Structure
INTERNAL
EXTERNAL
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Transitions Teams Composition Internal Team
Kim Lawson Medical Surgical Nursing Director Jody Gregory Critical Care Director Christi Cook Case Management/Social Work
Director Michelle Nelson Ambulatory Services Director Cindy Hoff Performance Improvement
Coordinator
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External Team Leaders Robin Moreno- External Team Steering Group and
Focus Groups facilitator
Mark Koch- NH/SNF Focus co leader
Linda Foley- NH/SNF Focus co- leader
Shelby Crabtree- Hospice focus group leader
Susan Chavez- Home Health focus group co leader
Becki Hamilton- Home Health focus group co leader
Karla Dwyer- LTACH/Rehab focus group leader
Roddy Atkins- Mental Health focus group leader
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Project Outline
Description of Team Integrations Team Collaboration What is the Purpose and expected
outcomes? AIM Statements
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AIM Statements
1. To Identify high risk patients and create a handover process to provide support to community partners
2. Decrease 30 day All Cause Readmission by X%TBD
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3. Improve Patient Satisfaction Scores on HCAPS Discharge question by 2% over previous year.
4. Increase Knowledge of health care providers in optimizing the handover process to prevent gaps in care transitions and adverse events.
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Today we will:
1. Review progress of external and internal care transition teams
2. Identify next steps with the teams
3. Provide update on discharge and readmission process
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External Teams Update
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Community Partners External Groups Home Health- North Texas and First Texas leading group.
Meeting every two weeks; Tuesdays 330-430pm. LTACH/Rehab- HealthSouth and Texas Specialty leading group. Meeting PRN basis. Nursing Homes/SNF-. Monterrey and Senior Care leading group. Meeting every other Wed 2pm. Hospice- HOWF leading group. Meeting monthly. Tue 4pm. Mental Health- Helen Farabee leads group. Focus: Develop Resource Directory and Mental Health First Aid Card. Meeting monthly. ALF’s-First meeting Nov 27th. Leaders: TBD Meeting: TBD PCP, Onc’s, CNT, CHC, Incompass, Ambulatory Physicians- Will not meet until groups have identified issues and worked thru corrective processes.
Facilitator: Robin Moreno, MHA-HSA
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BOOST Implementation Timeline
Planning Phase Activities:1-3 months August-November 2013
During planning phase, focus groups addressed:Review of BOOST manual, processes, meeting goals, 8p’s, GAP analysis Baseline assessmentsSWOT analysisFMEA process(variation of) and ID top three issues to address
Implementation Phase Activities:4-6 months December 2013- February 2014
Intervention Phase Activities:7-10 months March-May 2014
Project Surveillance & Management :10-12 months June- August 2014 Facilitator: Robin Moreno, MHA-HSA
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External Team Next Steps
Develop the Physician/PCP Team and align with existing internal/external team outcomes
Evaluate additional patient populations requiring special consideration, i.e. Homeless/Shelter
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Internal Team
1. Teach Back Education2. 8P’s Assessment Form3. Discharge Medication List 4. Discharge Binder
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Internal Team Next Steps
1. Rapid Cycle Trial of Nurse to Nurse Report
2. Develop Discharge Checklist incorporating areas identified in 8P’s
3. Create a discharge communication tool in the EMR utilizing info from the BOOST Gap assessment and discharge checklist tools.
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Post Acute Care Discharge Follow up
1. Heart Failure Phone Calls/Zone Cards
2. Heart Failure Clinic
3. Diabetic Phone Calls/Zone cards
4. Diabetic Education/Nutrition Referral Process
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Post Acute Discharge Follow up Next Steps
1. Pulmonary/COPD Discharge phone calls/Zone cards
2. Stroke Discharge Follow up process
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Discharge Planning Update
Discharge/Resource Center Process
Readmission Case Review and Follow up process
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Standard Referral Information
History & Physical All consults PT/OT/ST notes In-hospital Medication List – NOT THE
DISCHARGE MED LIST Lab results
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Special Occasion Information
Vital signs Respiratory info Swallow study Assessment and interventions I & O Nutritional documentation
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Discharge Information
Discharge med list Copy of physician progress notes IF TO HOME HEALTH Patient education Patient instructions
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Discussion/Q&A
Contact Info:
Michelle Nelson 764-6714Christi Cook 764-3095Robin Moreno 322-1672 Kim Lawson 764-3637Jody Gregory 764-3868Service Desk/IT Helpline 764-3242