1. Care Transitions- Easy as Child’s Play –Right? Bronwyn Bartle DNP, CPNP-AC/PC Duke Children’s Heart Center

2. I do not have any relevant financial relationships with any commercial interests to disclose. Disclosure Statement

4.  Do you have a script that drives your care transition from ICU  floor A. Yes B. No A few questions to get us started

6.  Do you have a script that drives your care transition from floor to home? A. Yes B. No Question #2

8.  Do you have a “transition of care meeting” with the care team and the family prior to transferring? A. Yes B. No Question #3

10.  Who calls the pediatrician prior to discharge? A. No one does B. Attending C. Fellow D. Nurse practitioner Question #4

12.  Is the family aware of “milestones” to be met prior to transitioning? A.Yes B.No Question #5

14.  Every time we make strides forward we find ourselves sliding backwards.  How can we make it more predictable than a roll of the dice? Do you ever feel Stuck in this game?

15. How can we feel less like this? - We try so hard to “get it right”, always feeling under pressure, hoping at the final hour it does not all blow up We know we cannot read into the future – but we have to prepare for it.

16. And more like this? Shift our thinking: Strategic, collaborative, shared goals, multidisciplinary

17.  What do you use to coordinate care transitions? A.Journey board B.Scripted handoffs C.We rely on one person to take care of this D.No one does this E.I’m not sure how it happens Great idea – but how do we get there?

19. It’s charted – why the extra step?  Its like story cubes – we all use each of the 6 sided dice to tell the patient’s story.  No one tells the story in quite the same way.  The end user is the reader of the story.

20.  Partner with entire care team-  Multidisciplinary  Engage all of your resources (social work, discharge planner, community resources, nursing staff)  Parent/family engagement  Critical to success  Secondary caregiver identified and trained  Teach back method  Transparency of goals Critical to shift your thinking

21.  Problem list – active and resolved  Medications  Patient’s current status and most recent changes  Procedures (and results)  Read the op note/cath report/echo yourself  Consulted services  Family update  Understanding, availability, concerns What needs to be communicated?

22. Where do I start??

25. How do we get out of the ICU?! Who will take care of us when we leave? Strategic Communication is Essential How will I do this at home??

26. before admission  Engages parents even before admission  Teach back method  Teach back method builds confidence  Listen to how they explain their child to other family members – a window into their understanding  Satisfies list-makers and slackers alike! same teaching  Ensures everyone receives the same teaching.  Visual reminders AT LEAST 24 hours  Always, always state – AT LEAST 24 hours of care Overwhelming? I think not…

27.  Reassure them that bumps in the road are to be expected - at EVERY transition point  Hands on practice, practice, practice is essential  Encourage them to ask questions  Knowledge is power – be clear in your communication For Parents

28.  Don’t be afraid to ask for clarity  Don’t accept “I’ve only taken care of them today”  Know what you want to know  Ask where the parents are on their journey  Face to face bedside hand off is best  Transition of care meetings are essential  Minimize free text options in charting  Know the integral part you play For team members

29.  Give careful thought to care transitions  Be transparent  Be sure the story you are writing is not a cliffhanger!  Supply the next caregiver with tools to succeed – whether that is the next provider or the parent or the pediatrician  The “system” you implement should run without you Take Home Points

30. For questions:  Bronwyn.bartle@duke.edu Bronwyn.bartle@duke.edu  919-681-2343