health care home and care transitions march 15, 2013
DESCRIPTION
Health Care Home and Care Transitions March 15, 2013. Hosted by RARE Operations Partners: Institute for Clinical Systems Improvement, Minnesota Hospital Association, Stratis Health. Our host today will be…. Kattie Bear-Pfaffendorf – Minnesota Hospital Association. - PowerPoint PPT PresentationTRANSCRIPT
Health Care Home and Care Transitions
March 15, 2013
Hosted by RARE Operations Partners:
Institute for Clinical Systems Improvement, Minnesota Hospital Association, Stratis Health
Our host today will be…
Kattie Bear-Pfaffendorf – Minnesota Hospital Association
Kattie Bear-Pfaffendorf is a patient safety/quality specialist with Minnesota Hospital Association. She focuses or Transforming Care at the Bedside, Partnership for Patients, Readmissions, and Perinatal Safety. Kattie holds a MBA and Lean Six Sigma Green Belt. Kattie has over 7 years of experience in the clinical laboratory including; pathology, cytology, histology and microbiology.
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March’s Conversation…
Health Care HomeAnd
Care Transitions
Sharing their work:Fairview Medical Group
More about the presenters…
Leanne Roggemann, RN, MPH, is the Director of Nursing for the Fairview Medical Group (FMG).
She is the Health Care Home lead for FMG. This work includes the implementation of care coordination and partnering across the system to establish a smooth process for care transitions from the hospitals and other care settings.
Leanne has worked for FMG for 26 years in many roles including the inpatient setting and the ambulatory clinic setting.
Leanne Roggemann, RN, MPH
More about the presenters…
Vicki has spent the last 12 years in care management leadership, and is currently working as the system director of care transitions for Fairview Health Services. During the past year Vicki led the implementation of a system-wide care transitions strategy focused on assuring the highest quality patient and family support experience. She has a 21 year history in case management and is recognized for program development, building cross-continuum care teams and administering patient-focused care models.
Vicki is a graduate of Loyola University, New Orleans, with a MSN in Health Care Systems Management. She also holds a bachelors degree in nursing graduating from College of St Catherine, St Paul.
Vicki Weber, RN, MSN, CMC
Health Care Home and
Care Transitions
Leanne Roggeman, RN, MPH Vicki Weber, RN, MSN, CMCDirector of Nursing Director of Care TransitionsFairview Medical Group Fairview Health Services
March 15, 2013
Health Care Home Standards
1) Access
2) Panel Management
3) Quality
4) Care Coordination
5) Care Planning
Detailed components of the standards
Access
• 24/7 access
• Alternative visits: telephonic, MyChart, RN MTM, behavioral health clinicians
• Communication/handoffs between care teams
Panel Management
• Disease specific patient lists
• Reporting workbench
• Population management tool
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Detailed components of the standards
Quality
• Clinical outcome data
• PDSA cycles at the local level to improve flow/clinical outcomes
• Patient experience/satisfaction
• Patient partners
Care Coordination
• High risk referral management
• Care transition handoffs
• Health maintenance reminders
• Pre-visit planning
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Detailed components of the standards
Care Planning
• After visit summary
• Disease specific action plans
• Complex care plans
• Emergency care plans
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Supportive Program Components
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Care Transitions
Transition/Hand-Off Communication•Summary of event
Physician SummaryAfter Visit SummaryPhone call/email/face-to-face discussionClearly telling the patient story, what occurred, and what suggested/required care interventions need to occur
•Results inImmediate information related to the patient’s hospitalizationConfirmation of post-discharge needs
Why Focus on Care Transitions?
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•Personalized care management focused on patient-centered goals (use of HCH POC)
•Enhanced alignment of continuum of care management
•Outcomes drivenSerious unmet needs resulting in poor satisfaction with careHigh rates of preventable readmissions
40% (4/10) in hospital beds do not need to be there (Improvement in Science Research Network)
Care Transitions Process
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1)Risk Stratification – identify the patient’s risk level – this will determine what level of transition services a patient may need.
2)Assessment/Triage – complete a clinical and/or psycho-social assessment to determine probable post-event needs. 3)Patient Story – understand:
What led to this event,What level of understanding the patient has about the event,The patient’s clinical/psychosocial history that impacted the event, The patient’s ability and willingness to work on changes to maintain care in his/her home setting, andWhat support the patient may need to carry out the plan.
Collaborative Partnerships
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Clinics•Clinic Care Coordinator role
Partner with Care Transitions Specialist during the patient’s hospital stayCommunicate transition plan to physician and health care team membersPost-hospital, work with patient to make adjustments in Medical Home Care PlanAct in the role of Patient Advocate to support care needs
Hospitals•Care Transition Specialist role
Partner with Clinic Care Coordinator on transition plan and patient’s continuum needsFacilitate communication among all health care providers, proactively preparing for the transitionPartner with patient/family to review Medical Home Care Plan, identify new goals, prepare for transition back to primary care provider
Successes/Challenges
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Identified SuccessesAssurance that follow-up needs will be met due to personalized hand-off with clinic/community partners
Greatly improved communication between hospital and clinic
Patients and families are more engaged in planning transitionsEasy identification of patients who are considered high risk, resulting in improved focus on those with the highest need
Identified ChallengesWe want to share information with non-Fairview providers
More work to be done, particularly in our emergency departmentsSkilled nursing facility transitions need a different type of hand-off (plan of care, why is the patient coming to them, medication reconciliation, orders confirmation)
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Questions?
Upcoming RARE Events….
•RARE Rapid Action Learning Day, April 23, 2013, (8:30 a.m. – 3:30 p.m.)Mpls. Marriot Northwest, Brooklyn Park,
MN
•RARE Webinar, ICSI will be hosting the May 2013 webinar. Stay tuned for more details.
