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Presentation on theme: "COMMUNITY PARTNERS TRANSITIONS IN CARE UPDATE 2014 Q1."— Presentation transcript:


2 Project Outline  Open lines of communication  Variations in Requirements for Facilities  Loop closure:  Physician input for patient care

3 Project Outline Structure INTERNAL EXTERNAL

4 Transitions Teams Composition Internal Team  Kim LawsonMedical Surgical Nursing Director  Jody GregoryCritical Care Director  Christi CookCase Management/Social Work Director  Michelle NelsonAmbulatory Services Director  Cindy HoffPerformance Improvement Coordinator

5 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

6 Project Outline

7 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

8 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.

9 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

10 External Teams Update

11 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 27 th. 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

12 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 assessments SWOT analysis FMEA 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

13 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

14 Internal Team 1.Teach Back Education 2.8P’s Assessment Form 3.Discharge Medication List 4.Discharge Binder

15 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.

16 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

17 Post Acute Discharge Follow up Next Steps 1.Pulmonary/COPD Discharge phone calls/Zone cards 2.Stroke Discharge Follow up process

18 Discharge Planning Update Discharge/Resource Center Process Readmission Case Review and Follow up process

19 Standard Referral Information  History & Physical  All consults  PT/OT/ST notes  In-hospital Medication List – NOT THE DISCHARGE MED LIST  Lab results

20 Special Occasion Information  Vital signs  Respiratory info  Swallow study  Assessment and interventions  I & O  Nutritional documentation

21 Discharge Information  Discharge med list  Copy of physician progress notes IF TO HOME HEALTH  Patient education  Patient instructions

22 Discussion/Q&A Contact Info: Michelle Nelson 764-6714 Christi Cook 764-3095 Robin Moreno 322-1672 Kim Lawson 764-3637 Jody Gregory 764-3868 Service Desk/IT Helpline 764-3242


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