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Published byShona Philomena Wood Modified over 9 years ago
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Best Practices in Documentation Transfer Amanda Robbins, APRN, MSTexas Health Harris Methodist Hospital Fort Worth Emily Belew, MHA, LNFA Brookdale Senior Living
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American Medical Directors Association (AMDA): 2010 Transitions of Care Clinical Practice Guidelines “Transitions of care involves the movement of a patient between care settings and the transfer of information with them to facilitate a seamless continuum of care and to enable patients’ wishes to be followed - no matter where in the continuum of care they are.”
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American Medical Directors Association (AMDA): 2010 Transitions of Care Clinical Practice Guidelines “Poorly executed care transitions increase hospital admissions, duplication of services, and waste of resources…” http://www.amda.com/tools/clinical/transitionsofcare.cfm
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Traditional Communication Model
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NTOCC Conceptual Model for Transitions of Care
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How are documents transferred? Delivery-System Level Clinician Level Patient/Family Level Current PracticesBarriers Inconsistent Without purpose Potentially harmful Do not focus on the patient/resident
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Barriers to Effective Care Transitions: Delivery-System Care settings working in “silos” Information systems – inoperable or incompatible Financial incentives Modification of drug regimens Insurance-driven changes Under-recognized issue to health policy makers
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Barriers to Effective Care Transitions: Clinician Continuity across care settings Multiple Referrals without relevance to the patient’s overall care goals Multiple Care Managers
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Barriers to Effective Care Transitions: Patient/Family Rarely advocate for improved transitions Not informed about disease processes Feel powerless Knowledge v. complexity of the current medical model Conflicting information Culture, expectations, barriers
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Recommended Best Practice? To ensure that patients and their critical medical information are transferred safely, timely, and efficiently. Transitions of Care Checklists Interventions to Reduce Acute Care Transfers
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