Presentation is loading. Please wait.

Presentation is loading. Please wait.

Transitions of Care: From Hospital to Home

Published byVerawati Tedja Modified over 5 years ago

Similar presentations

Presentation on theme: "Transitions of Care: From Hospital to Home"— Presentation transcript:

1 Transitions of Care: From Hospital to Home
December 2018 Learning Session

2 Background… The Transitions of Care Team is part of the overall Inpatient Bed Day Disparity Reduction project team Our Objective: 50% of Gen Peds primary care patients discharged from Hospital Medicine service have an *effective transition of care *Effective Transition of Care defined as: 48 hour contact after discharge (patient directed contact approach) Follow up appointment scheduled Medication Reconciliation reviewed After Visit Summary (AVS) reviewed

3 Transitions of Care Key Driver Diagram
Project Leader(s): Susan Wade-Murphy, John Morehous, Andy Beck Revision Date: 11/27/2018

4 It starts with a daily morning HUDDLE CALL
How does this work? MDs RN Care Managers Social Workers Discuss patient’s admitting diagnosis, preventive services status, discharge needs, social determinants, need for subspecialty referrals It starts with a daily morning HUDDLE CALL Patient Home Health RNs School Based Interventionalists School Based Nurse Practitioners If concern for prolonged admission or particular social or medical complexity, will plan for follow up discussion on the next huddle call Monitor daily for discharge and once discharged, patient receives effective transition bundle Escalation process established if patient unable to be reached and concerns remain high

5 Future Strategies for Spread
Current Focus Taking the well established Gen Peds process and collaborating with our Complex Care and Adolescent Medicine colleagues. We share continuity in process, elements reviewed at time of call, and documentation. We share similar struggles in reaching some patients. We plan to review shared data monthly (who do they capture, how are we all doing, what can we learn together…) Future Strategies for Spread Possible future plans include spreading to other chronic conditions managed by CCHMC specialists and community patients/partners

6 Measures and Results Established baseline to be 12 points We also track data on the individual bundle components Review of process reveals that most failures due to inability to contact patients

7 Thank you! We welcome any questions or further discussion… Contacts
Susan Wade-Murphy, RN John Morehous, MD Andy Beck, MD Asst VP - Patient Services General Pediatrics General Pediatrics

Download ppt "Transitions of Care: From Hospital to Home"

Similar presentations

RARE Action Learning Day, November 2012 Park Nicollet Post Hospital Discharge Follow Up Calls Karen Loscheider, RN Kris Kopski, MD, PhD.

RARE Action Learning Day, November 2012 Park Nicollet Post Hospital Discharge Follow Up Calls Karen Loscheider, RN Kris Kopski, MD, PhD.
Transitional Care Post Discharge; Tracking and Documentation.

Transitional Care Post Discharge; Tracking and Documentation.
Risk Assessment - What are we Learning? Stephanie Mudd RN MSM CCM Supervisor, Care Management TG/AH/MBCH 1 Presented by Washington State Hospital Association.

Risk Assessment - What are we Learning? Stephanie Mudd RN MSM CCM Supervisor, Care Management TG/AH/MBCH 1 Presented by Washington State Hospital Association.
Royal Wolverhampton Hospitals NHS Trust Medical Staff Induction Day Palliative Care at New Cross Hospital Dr Clare Marlow Dr Benoît Ritzenthaler Consultants.

Royal Wolverhampton Hospitals NHS Trust Medical Staff Induction Day Palliative Care at New Cross Hospital Dr Clare Marlow Dr Benoît Ritzenthaler Consultants.
Patient Centered Medical Home What it means for Duffy Health Center Board Presentation September 10 th 2012.

Patient Centered Medical Home What it means for Duffy Health Center Board Presentation September 10 th 2012.
Transitional care management (TCM): A team approach to facilitating transitions of care in a Gerontology Clinic Carol O’Leary, Jeffrey Kochka, Virginia.

Transitional care management (TCM): A team approach to facilitating transitions of care in a Gerontology Clinic Carol O’Leary, Jeffrey Kochka, Virginia.
Beginning the Day Care Transformation Collaborative of R.I. BEST PRACTICE SHARING MAY 5, 2015 KAREN SCIAMACCO, RN, BS, CCM, CDOE ASSOCIATES IN PRIMARY.

Beginning the Day Care Transformation Collaborative of R.I. BEST PRACTICE SHARING MAY 5, 2015 KAREN SCIAMACCO, RN, BS, CCM, CDOE ASSOCIATES IN PRIMARY.
Phase Two Learning Session 0 6 May 2013 Diana Dowdle - Campaign Manager David Grayson – Campaign Clinical Leader.

Phase Two Learning Session 0 6 May 2013 Diana Dowdle - Campaign Manager David Grayson – Campaign Clinical Leader.
Excellent Transitions: Reducing Readmissions Lana McKinney RN, Continuity of Care Service Director Mark Taylor MD, Hospital-Based Services Kaiser Permanente.

Excellent Transitions: Reducing Readmissions Lana McKinney RN, Continuity of Care Service Director Mark Taylor MD, Hospital-Based Services Kaiser Permanente.
Interprofessional Education M. David Stockton, MD, MPH Professor Department of Family Medicine UT Graduate School of Medicine Sept. 4, 2013.

Interprofessional Education M. David Stockton, MD, MPH Professor Department of Family Medicine UT Graduate School of Medicine Sept. 4, 2013.
Fresh Approaches to Patient Education Susan Savastuk MEd, BSN Stroke Program Coordinator Neuroscience Institute Bloomington Hospital Bloomington, IN 1.

Fresh Approaches to Patient Education Susan Savastuk MEd, BSN Stroke Program Coordinator Neuroscience Institute Bloomington Hospital Bloomington, IN 1.
Part I (AAP QI) - Results Ruth S. Gubernick, MPH Quality Improvement Advisor Florida Pediatric Medical Home Demonstration Project Learning Session 3 December.

Part I (AAP QI) - Results Ruth S. Gubernick, MPH Quality Improvement Advisor Florida Pediatric Medical Home Demonstration Project Learning Session 3 December.
General Medicine Improving Quality Care Presenter: Jane Lees Health Service: Auckland District Health Board Innovation Poster Session HRT1215 – Innovation.

General Medicine Improving Quality Care Presenter: Jane Lees Health Service: Auckland District Health Board Innovation Poster Session HRT1215 – Innovation.
MiPCT Embedded Case management Barriers to developing an embedded Case Management program.

MiPCT Embedded Case management Barriers to developing an embedded Case Management program.
A Holistic Approach To Discharge Planning. Due to the regulatory guidelines and changes in healthcare for example: Bounce backs Reduced hospitalizations.

A Holistic Approach To Discharge Planning. Due to the regulatory guidelines and changes in healthcare for example: Bounce backs Reduced hospitalizations.
DATA AND ER VISITS ASSOCIATES IN PRIMARY CARE MEDICINE’S ASSESSMENT AND PLAN.

DATA AND ER VISITS ASSOCIATES IN PRIMARY CARE MEDICINE’S ASSESSMENT AND PLAN.
When Location Doesn’t Matter: When the Quality of Care is at Stake Johanna Warren MD, Jessica Flynn MD, and Scott Fields MD MHA Oregon Health & Sciences.

When Location Doesn’t Matter: When the Quality of Care is at Stake Johanna Warren MD, Jessica Flynn MD, and Scott Fields MD MHA Oregon Health & Sciences.
Mayo Clinic Home Connection Thomas R Harman, M.D. Mayo Clinic, Rochester.

Mayo Clinic Home Connection Thomas R Harman, M.D. Mayo Clinic, Rochester.
Innovations in Primary Care: Implementing Clinical Care Management in Primary Care Practices Judith Steinberg, MD, MPH Deputy Chief Medical Officer Jeanne.

Innovations in Primary Care: Implementing Clinical Care Management in Primary Care Practices Judith Steinberg, MD, MPH Deputy Chief Medical Officer Jeanne.
Utilization of Care Coordinators in Patient-Centered Medical Homes Elizabeth Beck MS(c), BSN, RN Mary Jo Welker, MD Randy Wexler, MD.

Utilization of Care Coordinators in Patient-Centered Medical Homes Elizabeth Beck MS(c), BSN, RN Mary Jo Welker, MD Randy Wexler, MD.

Similar presentations

Ads by Google