transition of care communication
DESCRIPTION
Transition of Care Communication. f rom the perspective of the outpatient clinic. Nystrom & Associates, Ltd. Minnesota Based Mental Health Clinic with eight Minnesota locations and two Washington state locations. Over 40,000 unique patient visits per year. Patient population breakdown: - PowerPoint PPT PresentationTRANSCRIPT
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Transition of Care Communication
from the perspective of the outpatient clinic
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Nystrom & Associates, Ltd. Minnesota Based Mental Health Clinic with eight Minnesota locations
and two Washington state locations. Over 40,000 unique patient visits per year. Patient population breakdown:
50% State / Federal Funded (Medicaid / Medicare)
Large commercial payer mix (Blue Cross Blue Shield, Medica, Preferred One, Etc)
Small cash pay population
Collaborative partnerships with many MN, WA, and National Organizations: Nexus (Mille Lacs Academy, Gerard Academy)
Prairie Care
Health Partners
Medica
Multicare Associates (Fridley, Roseville, and Blaine Medical Centers)
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RARE – The Five Key Areas Patient / Family Engagement and
ActivationMedication ManagementComprehensive Transition Planning Care Transition SupportTransition Communications
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Patient / Family Engagement and Activation Systemic communication is important from
the start! The value of the referring entity in getting
Releases of Information. Family System involvement expectations
from point of referral on. This is an active discussion and dialogue!
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Medication ManagementThe importance of accuracy.Dossing expectations and
communication.Existing medicationsCross Clinic / Provider illness management.
Additional resources – Family, Friends, Case Workers, Group Homes, Etc.
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Comprehensive Transition Planning Clear plan of services What follow up, when, where, goals? Communication of documentation and
information from referent Set up release of information and
communication expectations with patient at this time.
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Care Transition Support
Timelines for care – clear expectations on urgency (NCQA, Joint Commission, Patient Need)
Care needs, medication management, community services, psychotherapy, chemical dependency, etc.
The key to a good referral Patient buy in, informed consent, clear
communication and expectations
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Transition Communication - The Culmination of the 5 Key Areas Back and forth communication expectations.
Needs of referent, needs of the clinic, needs of the patient
Release of information on both sides.
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Independent control – what are we able to take ownership of vs. what do we need to depend on other for.
Clear expectations on all areas from the start.
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Collaborative Partnerships and Care CoordinationValue of formalizing collaborative
partnershipsUse of a small handful of providers or
one provider vs. manyCommunication expectations – what to
bring to the table
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Time makes allall things fuzzy
Over time memory fades.
Importance of writing it down. Referral guidelines
Memorandum of Understanding
Contracts
Periodic review and check in
If it doesn’t work, FIX IT!
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Clear expectations from day 1 Who is involved? How do they communicate? When it breaks, who is going to fix
it? Did you write it down?
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When good intentions fail
The “set it and forget it” mentality Assumptions hurt patients care Failure is an opportunity – Do not overlook
it!
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