Address Readmission Rate Robust inpatient management but need for streamlined community navigation HF patients have been using the ED as primary care.

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Presentation transcript:

Address Readmission Rate Robust inpatient management but need for streamlined community navigation HF patients have been using the ED as primary care Intensify Heart Failure patient discharge education to start on admission

Heart Failure Self Management Book One-on-one patient education HF follow-up: phone, Cardiac Rehab referral, PCP Intensify Heart Failure patient discharge education to start on admission hospital wide involvement Streamline community resources Heart Failure Support Group

DATESENCOUNTERSEDUCATIONTELEPHONE/ FOLLOW UP May ‘12 – Dec ‘ Jan ‘13 – Dec ‘ Jan ‘14 – Feb ‘ TOTAL

Rapid Diuresis protocol Utilization of CPC Mid-level managed clinics

Grow Support Group Regional Education and Outreach Streamline involvement with population health, community navigation and faith based network Integrate care between inpatient-outpatient-PCP Full utilization of cardiac rehab

TJC Disease Specific Certified 4 in the State of Texas ADA Recognized Diabetes Self Management Program 102 in the State of Texas 1758 in the United States

High undiagnosed rate of diabetes in Ector County Community unawareness of resources Meaningful education and screening process Restructure the process to be: Risk StratificationScreen CBG/A1CEducationPCP/Follow Up

Diabetes community health education Meaningful Screening Tool Education Piece Risk Stratification and Self Assessment CBG testing / A1C Taking the tool to the community/ health Fairs Scheduling free Survival Skills 2-3 hour class in English and Spanish

4 Hours Core Class and 3 Hours of Nutrition 3 Hours shadow with clinical educator Designed for organizations without any Nursing Education Department or Diabetes Educators End goal: Staff will develop beginning skills and working knowledge on helping patients with diabetes Permian Regional Medical Center – Andrews Pecos County Memorial Hospital – Ft. Stockton

Regional Outreach/ Education in collaboration with PRMC and PCMHFS Grow the current APN based providers for those without PCPs and referred to ProCare Streamline involvement with population health, community navigation and faith based network Integrate care between inpatient-outpatient-PCP

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