EMPOWERING NURSES TO LEAD

EMPOWERING NURSES TO LEAD
ND Center for Nursing FUTURE OF NURSING CAMPAIGN FOR ACTION

NAVIGATING THE COMPLEX HEALTH SYSTEM
A Primer for The Nurse

Authors of this Module Joan Bachman, RN, NHA, RHIT, BSBA, FCN
Julie Traynor, RN Eric Christofferson, RN Jeanine Senti, RN, Amanda Holland, RN Julie Bruhn, RN, Shelly Graenning, RN Kelly Hagen, RN Michelle Lauckner, RN Shawn Brooking, RN, NP Mary Wright, RN

Leadership Program is divided into 4 main areas
Leadership Program is divided into 4 main areas. Communication is foundational for learning and understanding about systems. Knowledge of how systems function is necessary to institute change. The ability to accept and engage in change is necessary to be an advocate for health policy. All nurses are expected to lead!

PURPOSE OF THIS MODULE To increase your understanding of how knowledge of the healthcare system will help you, the nurse, provide patient-centered care to guide each patient toward desired health outcomes.

WHAT IS NURSING Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations. ANA

THE PATIENT Life-style Diagnoses Treatment options Income
Family obligations Hopes/dreams Culture Education Support systems The patient, not the diagnoses should be the center of the discussion.

What is a Complex System
A complex system is a system composed of interconnected parts that as a whole exhibit one or more properties (behavior among the possible properties) not obvious from the properties of the individual parts

SILOS The American healthcare system … isn’t. It isn’t a “system.” Patients have multiple providers. These providers rarely interact. The payment system operates in silos. And patient care isn’t coordinated. SILO SYSTEM Diagnosis $$ Treatment Followup Problem Problem Diagnosis Treatment Followup $$$

KNOWLEDGE OF “SYSTEM” The Problem The Solution
“it is in inadequate handoffs that safety often fails first” “nurses are the health care professionals most likely to intercept errors and prevent harm to patients” providers/resources/nursing/resources/nurseshdbk/index.html The Solution Be aware of the many facets of the System Recognize “how things work” – and why Know who is responsible Realize complexity/barriers – seen by you: seen by patient Know that patients may need help to identify sources of service & make decisions

OBJECTIVES 1. Review the health care system’s provider types and levels of service, regulation, and reimbursement mechanisms; 2. Investigate your organization’s structure and processes; 3. Describe your position/role within the organizational structure; and 4. Demonstrate your knowledge of the health care system to help a patient (and family) consider and access viable options for achieving personally desired health outcomes.

To Earn Contact Hours You Will Submit
A description of your employer on the provided worksheet A description of your position on the provided worksheet To Earn Leadership Recognition You Will Submit A case study of a successful handoff of a patient using the provided outline

Community Outpatient Inpatient In-home
1. Review the health care system’s provider types and levels of service, regulation, and reimbursement mechanisms Types of Providers Community Available to the community at large or a specific segment of the population for prevention, support, or treatment Outpatient The patient receives treatment and services; remains less than 24 hours Inpatient The patient stays overnight for treatment, support, and lodging A hospital Medicare “Observation” patient is considered an outpatient in terms of reimbursement even though housed for up to 5 days in a hospital bed. This designation is being contested. In-home The patient receives prevention, support, and treatment services in the individual’s private home or in a current place of residence such as a group home or assisted living facility that does not prohibit such services

PROVIDER OWNERSHIP & MANAGEMENT
“General Providers” – Available to qualified general population Religious Organizations ‘Community’ owned Privately owned Government owned Special Population Providers Veterans Health Administration (VAMC) Indian Health Service (IHS) Migrant Health Services Public Health Services (PHS) Government owned Homeless Nonprofit group homes

COMMUNITY HEALTH PROVIDERS
Public Health – Counties/Cities Rural Health Clinics , FQHC -- WIC School Nurses Wellness/Fitness Centers Vaccination Clinics Faith Community Nurses Community Action Agencies Social Service/Mental Health Agencies Durable Medical Equipment Suppliers Pharmacies Industrial Health – may be limited to certain employees Shelters/Halfway Houses Foster Care Adult Day Care – Respite Care Providers Foot Clinics Home Health Care Group Homes for Physical and Social issues

OUTPATIENT PROVIDERS Medical Clinics – 305 est (52 RHC, 7 FQHC) *3,679,739 est. visits Ambulatory Surgery Centers – 12 Renal Dialysis Centers (ERSD) – 16 Physical, Occupational, Speech Therapy * hospital-based clinics

MORE OUTPATIENT PROVIDERS
Comprehensive Rehabilitation Facility (CORF) Cardiac and Wellness Centers Chiropractic Clinics Pharmacies Addiction/Mental Health Therapy – 54 Telehealth – Appointments and Therapy Management

MORE OUTPATIENT PROVIDERS
Adult Day Care – Respite Care and In-Home Aging Services Diagnostic Services Laboratory Radiology Screening – Providers, Practitioners, Pharmacies, Health Fairs Telehealth – Providers, Practitioners

INPATIENT PROVIDERS Hospital – 51
97,028 inpatient admissions; 337,451 ER visits; 1,702,920 OP visits in 2012 Acute General Critical Access – Swing Bed (LTC) - 37 Prospective Payment – 6 Rehabilitation - 1 Long Term Acute Care - 2 Acute Psychiatric - 3 Acute Special – transplantation - 2 Nursing Facility ,213 residents in 2012 Intermediate Care Facility for Intellectual Disabilities Prospective Payment Hospitals are held to ‘original’ federal and state hospital standards of licensure & certification and are reimbursed by Medicare based on average costs associated with Diagnosis Related Groups (DRGs). Critical Access Hospitals have fewer than 25 beds, are held to amended federal and state standards and are reimbursed by Medicare based on cost. This designation of hospital was first certified and licensed in 1995 to retain financially viable acute inpatient care in rural America. Swing beds are long term care beds. North Dakota requires all Nursing Facilities to be Medicare/Medicaid certified.

MORE INPATIENT PROVIDERS
Basic Care Facility – 68) ,152 residents in residents in 2012 Assisted Living Facility – ,195 residents in 2012 Hospice – 13 “Treatment” Centers - (Mental Health/Substance Abuse) Group Homes Basic care often a wing of nursing facility

IN-HOME PROVIDERS Home Health – 35
Therapy -- Physical, Occupational, Respiratory, Speech Personal Care – Family, Private, HCBS (Home & Community Based Services) Homemaking Hospice – 13 Telehealth Diagnosis -- Lab draws, Mobile radiology

EXAMPLE - PROVIDER “SYSTEMS”
Single Facility “System” e.g., Prospective Pay Hospital – Emergency, Med-surg, Obstetric/neo-natal, Surgical, Coronary Care, Critical Care, Transitional Care, Rehabilitation Unit, Palliative Care Co-located Facilities e.g., Locally Owned Facility ‘Continuum’ Hospital, Clinic, Nursing Facility, Assisted Living, Home Health “Owned”/“Managed” System e.g., Regional ‘Parent’ Organization – (Sanford, Altru, Essentia, Trinity, St. Alexius) Hospitals, Clinics, Nursing Facilities, Assisted Living, Home Health, Hospice, Wellness Centers “Owned” “Systems” National Managed Care Organizations (HMO) – i.e., Rugby, Sanford, Kaiser Co-located relates to separately licensed providers under the same roof/management

INDEPENDENT HEALTH PRACTITIONERS
Physicians – Primary and specialty care – 3, PAs Dentists - 455 Pharmacists Advanced Practice Nurses – 558 with prescriptive authority Optometrists/Opticians Chiropractors

MORE INDEPENDENT HEALTH PRACTITIONERS
Psychologists Counselors Addiction Counselors Podiatrists Massage Therapists

LEVELS OF SERVICE Preventive – Clinic, Community
Acute Care – Clinic, Hospital Chronic Care – Clinic, Hospital, Long Term Care, ESRD, In-Home Care Palliative Care – Hospital, Nursing Facility, Basic Care, Assisted Living, Home Health, Hospice Long term Care – Nursing Facility, Swing Bed, Basic Care, Assisted living, In-Home Care The goal would be to have Preventive always the first level

PREVENTIVE SERVICES Community Services – treatment, education, support, referral Family services – domestic, financial Support Groups Nutrition Personal care Wellness Centers – training, education, support Medical Clinic –screening, diagnosis, education, referral Hospital – diagnosis, treatment, education, referral Outpatient Providers – screening, diagnosis, treatment, support Therapies – diagnosis, treatment, training, education, referral

ACUTE SERVICES Medical Clinic – emergencies/scheduled visits, diagnosis, treatment, education, referral, social media – text messages, phone follow-up, Ambulance – First Responders – Emergency Services (fire, police, homeland security, Red Cross, Salvation Army, etc.) Hospital – emergencies/scheduled admissions, diagnosis, treatment, education, referral, social media – text messages, phone follow-up, Outpatient Providers – scheduled diagnosis, treatment, education, referral, support, social media – text messages, phone follow-up

CHRONIC CARE SERVICES Clinic – screening, diagnosis, treatment, education, referral Hospital – diagnosis, treatment, education, palliative care, referral ESRD - treatment Long Term Care Providers – diagnosis, treatment, education, personal care, , palliative care, support In-Home – treatment, personal care, palliative care, support Community – treatment, education, support, transportation, referral

LONG TERM CARE SERVICES
Assisted Living – lodging, meals, optional services (Med Management, diet) Basic Care – lodging, personal care, med management, nutrition, activities Nursing Facility – lodging, personal care, treatment, skilled nursing, In-Home - personal care, treatment, skilled nursing Group Homes – housing for treatment, support, supervision Mental Illness Developmental Delays Traumatic Brain Injury Addictions

WHO DEFINES PROVIDERS & SERVICES “Outside Forces”
Government Forces Legislature – Laws City - Regulations & Enforcement State agencies – Regulations & Enforcement, Reimbursement Licensing Agencies (Health, Human Services, Professional Boards) Congress – Laws Federal Agencies – Regulations & Enforcement, Reimbursement Department of Health & Human Services Centers for Medicare and Medicaid, VAMC, IHS FDA, DEA, OSHA, CDC, DOL Unlike most business models, health care is subject to many outside forces that may or may not be involved directly in the business of providing health and medical services. This intense outside pressure can have negative influence to Provider and Practitioner development of most patient-friendly services. FDA – Food & Drug Administration DEA – Drug Enforcement Administration OSHA – Occupational Safety and Health Administration CDC – Centers for Disease Control DOL – Department of Labor

Nongovernmental Governing Bodies
More “Outside Forces” Nongovernmental Governing Bodies Health Care Industry - Financial Viability, Patient Demands, Workforce Availability Insurance Carriers – Financial Viability, Population, Marketplace Technology & Pharmaceuticals - Research/Development, Financial Viability, Marketing Public – Liability suits, (Lack of) Advance Directives, Requests and Demands for Service Professional/Trade Organizations – Education, Lobbying, Research Academia – Education, Research Governing Body(ies) of a Facility (Board of directors, owners, medical staff, and department heads – even the community) establish direction; determine scope of services; determine financial status; establish personality. Professional Associations keep membership informed on changes and regional or national issues; advocate for providers with legislative lobbying; offer education; afford peer support. Provider Organizations keep membership informed on changes and regional or national issues; advocate for providers with legislative lobbying and marketing efforts; offer education; afford peer support Institutions of Higher Learning set the attitude and abilities of students; perform research that leads to new treatment and technology; develop clinical expertise and standards; contribute to standards of ethics. Payers of Service define elements of services (allowable/covered vs. non-allowable/uncovered): not always coherent with regulations and standards of (clinical) practice. Government pays for a lion's share of the health care that is delivered and determines what is covered or not. Insurance companies have stock-holder profit motives. The general public who utilize health care services generally expect to rely on the health care delivery system to fix them when something goes wrong. Customers have the least impact on governing the health care system except by seeking alternative providers

THE REGULATION OF HEALTH CARE
Licensure – State -- description of service & enforcement the state or condition of having a license granted by official or legal authority to offer specific services and take specific action not permitted by persons without such a license: i.e. Registered Nurse, Pharmacist, Hospital, etc. (edited) Certification – Federal -- Medicare/Medicaid – description of service & payment The Social Security Act (the Act) mandates the establishment of minimum health and safety and CLIA standards that must be met by providers and suppliers participating in the Medicare and Medicaid programs. These standards are found in the 42 Code of Federal Regulations. The Secretary of the Department of Health and Human Services has designated CMS to administer the standards compliance aspects of these programs. Some individual professions are ‘certified’ rather than ‘licensed’ Accreditation - The Joint Commission, etc. – No regulatory authority. CMS Contractor Joint Commission standards are the basis of an objective evaluation process that can help health care organizations measure, assess and improve performance. The standards focus on important patient, individual, or resident care and organization functions that are essential to providing safe, high quality care. The Joint Commission’s state-of-the-art standards set expectations for organization performance that are reasonable, achievable and surveyable. Accreditation is not legally regulatory although based on CMS regulations Licensure of an entity or individual requires certain conditions to be met by anyone holding that license. This establishes standardization of definition. Compliance with licensure requirements is evaluated by the licensing agency. Certification of an entity or individual requires certain conditions to be met by anyone holding that license. Certification requirements for compliance with Medicare and some Medicaid providers are enforced under contract by State departments of health Certification requirements for compliance with some Medicaid providers are enforced by State Medicaid agencies Accreditation is a voluntary quality measurement system, with payment by the accredited entity. Some compliant accredited agencies are deemed to be in compliance with Medicare certification requirements.

ENFORCEMENT OF REGULATIONS
Applicable to Providers and Practitioners Letter of Reprimand Warning with Plan of Correction (POC) Disciplinary Action - Notification Civil Money Penalties Limit Scope of Practice Limit Reimbursement Termination of Licensure or Certification Prohibition from Participating (future)

REIMBURSEMENT FOR HEALTH SERVICES
Private Health Insurance (much based on Medicare Rules) Premium paid by insured and/or employer Payment for covered services by participating providers Private Self Pay For uninsured patients or non-covered services Medicare For age and disability qualified Payment for covered services by participating qualified providers Medicaid For income, age , and disability qualified Population based VAMC, IHS, Migrant Health, Public Health For specific populations for covered services by participating qualified providers Reduced fees (sliding scale based on income) and Free (charity care) When there is no other pay source Providers (except hospitals) may choose to not accept/treat patients with no payment source Rugby Hospital had the first HMO in North Dakota – many years ago. And it still operates successfully

DEFINITIONS Covered Services Participating Providers/Practitioners
Medical and health care services as defined by the paying agency. Restrictions vary by paying agency and specific coverage plan. i.e., a. May require specific sequence of diagnostic tests or treatments to qualify for payment; b. Pay for specific treatment for only specific diagnosis. Neither the patient nor the provider or practitioner decides what is a covered service although both agree by virtue of the contract with the paying agency Participating Providers/Practitioners Qualified Providers and Practitioners who have an agreement with the paying agency for certain services under certain conditions Qualified Providers/Practitioners Providers/Practitioners who are licensed or credentialed to perform the service for which payment is requested Prospective Payment System A means of determining reimbursement to hospitals based on predetermined prices, commonly determined by Medicare. Payments are based on codes such as Diagnosis-related Groups (DRGs) “bundled”, Ambulatory Payment Classifications (APCs) “bundled”, or Current Procedural Terminology (CPTs) Fee for Service – Cost-based Services and supplies are unbundled and charged separately

MORE DEFINITIONS Premium Deductible Medicare Part A Medicare Part B
Payment by the insured for coverage Deductible Agreed dollar amount to be paid by the insured before payment by paying agency Medicare Part A Medicare Coverage for Hospital Stays Medicare Part B Medicare Coverage for Covered Outpatient Services Medicare Part D Medicare Drug Coverage Co-Pay Agreed dollar amount for insured to pay for health services (not the deductible)

On the Horizon? Medical Homes
The patient-centered medical home is similar to managed care approaches and health maintenance organizations, but asks providers to focus on improving care rather than managing costs. A continuous relationship with a Personal Physician coordinating care for both wellness and illness using these Elements: Practice Management, Health Information Technology, Quality and Safety, Practice-based Care Team, Care Coordination, Care Management, Practice-based Services, Access to Care and Information Effect of ACA on health status unknown. Costs projected to increase .

Organizational Structure
2. Investigate your organization’s structure and processes; EMPLOYER ORGANIZATION Legal Description Licensure – Certification – Accreditation – Organizational Structure Ownership - Corporation, proprietorship, partnership, government For Profit/Nonprofit Single site? – Multiple sites? Related Providers Organizational Governance Who is responsible Mission/Vision Statements Teaching Site ? From Employer Agency Annual Report or Website

ORGANIZATIONAL CHART Visual representation of how a firm intends authority, responsibility, and information to flow within its formal organizational structure. It usually depicts different management functions (finance, human resources, marketing, nursing, environment,) and their subdivisions as boxes linked with lines along which decision making power travels downwards and answerability travels upwards. It is helpful for you to understand how the functions and departments within the organization are related and communicate. You will be able to use this information to develop and promote your leadership skills.

EMPLOYER DESCRIPTION Services Provided Population Served
Community Involvement Management Team Hiring, Orientation, Training, Retention Level of Decision-making Policies Procedures/Processes Quality Assessment/Performance Improvement Research Annual Report of the organization for services and population. Personnel handbook will describe organizational hierarchy and employment policies. Descriptions of Policies, Procedures, and Quality systems and your relevant role will be readily available to all employees.

REFLECT ON YOUR EMPLOYER ORGANIZATION
Accurately describe the Provider Type(s) and Services provided What are Operational Priorities - from Mission Statement from Your Perspective What is the political climate -? Within the organization Within the Community What are usual referral patterns? – in and out What is the status of employees? What is the status of patients? Complete the Handout – Employer Organization Worksheet

Organizational Location -- refer to chart (reporting & accountability)
3. Describe your position/role within the organizational structure; NURSING DEPARTMENT Organizational Location -- refer to chart (reporting & accountability) Intra-Organizational Communication Clear Expectations Two-way Interactions Patient Care Policies Staffing Patterns Contribute to Organizational Decision-making? 42

What is your position title? Do you ‘fit’ your position?
Your Position within the Department Level of Responsibility & Accountability What is your position title? Do you ‘fit’ your position? Do you practice your leadership skills? With peers With supervisors With other disciplines and departments Do you have & use opportunities for growth? Complete Handout – Job.Communications

Be Trusted and Trusting
4. Demonstrate your knowledge of the health system to help a patient (and family) consider and access viable options for achieving personally desired health outcomes. WHAT CAN I DO? Be Trusted and Trusting Accountable Responsible Be Mindful – Be “in-the-moment” Nonjudgmental awareness of the present Reflect Know that you don’t know (everything) Use Personal skills to influence – from THIS Position Empower – self, co-workers, patients Teach – Facilitate (Coordinate !) – work environment, relationships, patient services

U.S. HEALTHCARE DELIVERY SYSTEM Jones & Bartlett, Not for Sale Or Distribution

NURSING PROCESS AND PATIENT HANDOFFS
Nursing Process: a five-part systematic decision-making method focusing on identifying and treating responses of individuals or groups to actual or potential alterations in health. Includes assessment, nursing diagnosis, planning, implementation, and evaluation. Bexhill-on-Sea, UK, MediLexicon International Ltd © All rights reserved. International Ltd, --- a successful Hand-Off is defined as a transfer and acceptance of responsibility for patient care that is achieved through effective communication. It is a real-time process of passing patient specific information from one caregiver to another or from one team of caregivers to another to ensure the continuity and safety of that patient’s care. A hand-off process involves “senders,” the caregivers transmitting patient information and transitioning care of a patient to the next clinician, and “receivers,” the caregivers who accept patient information and care of that patient.

THE NURSE CAN FOSTER A SYSTEMS APPROACH HANDOFF
Nurse is primary to patients (leader of the care team) First connection in most any setting Has access to diagnosis, plan of care, desired outcome Knows Patient vulnerabilities Last connection in most any setting Nurse most trusted of care-givers Nurse facilitates Care Coordination: internal & external

PATIENT EXPERIENCE From ND HCRI
Abrupt transitions between settings Brief hospital days Sudden self-management with minimal preparation Poor communication between care providers National Perspective Hackbarth, Reischauer, and Miller. Medicare Payment Advisory Committee 1 in 5 Medicare beneficiaries are readmitted to the hospital within 30 days 1 in 3 beneficiaries are readmitted within 90 days 2 of 3 patients with medical conditions are either rehospitalized or die one year after discharge 90% of rehospitalizations were unplanned 76% of 30-day readmissions are potentially preventable

BARRIERS TO ACCESS TO SERVICES & SUCCESS OF HAND OFF
Mixed Priorities – Patient vs System Financial Legal Language/Cultural/Belief System Educational Generational Geographic No primary provider – regular source of care Patient looking for something different than health care team plans Lack of Advance Directives – patient advance planning Family has different ideas Lack of pay source No patient understanding of cost of care due no financial responsibility Nonmedical expenses may be devastating -- bankruptcy Unrealistic expectations – “miracle cure” Lack of communication or poor comprehension of communication Differences in social and moral issues Growing population new to USA ideas of Speak to patient’s level of understanding Distinct generational expectation and belief differences 6. Access to services may be limited where patient wants them

FINANCIAL BARRIERS Lack of insurance Lack of employment
Lack of Coordinated Care Multiple providers and levels of service Unwilling to make personal investment Little knowledge of cost of service Limited Understanding of 3rd Party Payment Incomplete Medical Documentation & Coding Medicare “Observation” vs “Inpatient” status (Hospital stays)

LEGAL BARRIERS Advance Directives - or lack of Vulnerable Adults
Dysfunctional family dynamics Licensing Laws for Providers and Practitioners Medical Errors Incomplete Medical Documentation & Coding

Barriers LANGUAGE/CULTURE/BELIEFS/EDUCATION
Stereotyping, biases – by Staff Limited or no English Access to professional interpreters Traditional health beliefs and practices (non-western medical practices) Access to social services Life-styles Dress Grammar Uncertainty of care-givers Organizational disregard Competency 1: Apply knowledge of social and cultural factors that affect nursing and health care across multiple contexts. Competency 2:Use relevant data sources and best evidence in providing culturally competent care. Competency 3: Promote achievement of safe and quality outcomes of care for diverse populations. Competency 4: Advocate for social justice, including commitment to the health of vulnerable populations and the elimination of health disparities. Competency 5: Participate in continuous cultural competence development. Journal for Nurses in Professional Development & Volume 30, Number 1, 29Y33 & Copyright B 2014 Wolters Kluwer Health | LippincottWilliams & Wilkins

GENERATIONAL BARRIERS

GEOGRAPHIC BARRIERS Transportation Weather Rural & Inner City
Limited access to health and community resources Limited technology connections Limited transportation Limited support services Homebound Limited technology capability Limited support services

DEVELOP A PLAN TO ASSIST YOUR PATIENT TO MOVE INTO/ACCESS REQUIRED LEVEL OF SERVICE BASED ON
Diagnosis Treatment Preferred site (inpatient, outpatient, home) Support resources Transportation Pay source Activities of daily living Instrumental activities of daily living Supply delivery

THE PATIENT ENCOUNTER Decision for medical intervention
Initial Nursing Assessment Practitioner Diagnosis Treatment Discharge Nursing Assessment Discharge Planning Handoff to Next Destination as Possible (or not) Comply

THE PROVIDER/PRACTITIONER ENCOUNTER
Admit Assess. X-Ray Lab & Diagnose Treat Document Discharge/ Refer Bill Insurance & Patient

THE NURSE ENCOUNTER Consider Admission from Where
Nursing Assessment Treat. Care. Coordinate Consider Patient Preferred Outcome Consider Patient/ Family Resources Consider Potential Barriers Plan with Patient/ Family for Discharge Teach, Demonstrate, Question. Handoff to Next Destination

THE REIMBURSEMENT ENCOUNTER
Access Documentation Transcribe dictation Analyze all documentation & reports Code Diagnosis & Procedures Submit codes for billing

WHY CARE COORDINATION? Patients and families hate it that we can’t make this work Poor hand-offs lead to delays, lapses in care, adverse drug effects, and other situations that may be dangerous to health Ensure transfer of correct information Provide patient support to wellness Track referrals & help resolve problems Less waste Enormous waste is associated with duplicate testing, unnecessary referrals, unwanted specialist-to-specialist referrals, and failed transitions from hospitals, EDs, & nursing homes. Clinical practice will be more rewarding Fewer problems – for patient and for health system Improve the health of the population Encourage personal responsibility for health status

WHAT IS HANDOFF OF CARE COMMUNICATION?
“Handoff of Care” communication is real-time, interactive process of passing patient specific information from one caregiver or team to another for the purpose of ensuring the continuity and safety of the patient’s care. Handoff of Care: Frequently Asked Questions. I Heal. Investing in our Expertise. University of Virginia

ELEMENTS OF HANDOFF OF CARE
An established “system” for change in responsibility for patient care Accurate and complete documentation Patient Identification, Diagnoses, Events, Anticipated Outcomes Patient education and understanding Verbal Communication Verification of available resources Shared Responsibility (for the Patient)

INEFFECTIVE HANDOFF At the heart of this coordination is assessing patients’ and families’ readiness to manage their care and their capability to do so. We should NEVER assume that they can do it all on their own. ndhcri video Rural Hospital Transfer Decision-Making: A Qualitative Approach Patricia Moulton, PhD Mary Wakefield, PhD, RN Alana Knudson, PhD Rob Beattie, MD Marlene Miller, MSW Presentation at the National Rural Health Association Annual Conference May 9, 2008, New Orleans, Louisiana

PATIENT REFERRAL RESOURCES
ND Dept of Health --- health facilities ND Dept of Human Services Available to all ND Residents Adult Services ND Dept of Health – Children’s services Mental Health and Substance Abuse Treatment Centers

TO READ ◊ Brian D. Smedley, Adrienne, Y. Stith, and Alan R Nelson, Editors. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care Committee on Understanding and eliminating racial and ethnic disparities in health care. Institute of Medicine ◊ A Distinctive System of Health Care Delivery – Jones & Bartlett Publishers (recommended*) ◊ V M Arora, J K Johnson, D O Meltzer, H J Humphrey: A Theoretical Framework and Competency-based Approach to Improving Handoffs. Quality Safety. Qual Saf Health Care : doi: 1136/qshc ◊ Quyen Ngo-Metzger MD, MPH*, Michael P. Massagli PhD, Brian R. Clarridge PhD, Michael Manocchia PhD, Roger B. Davis ScD, Lisa I. Iezzoni MD, MSc and Russell S. Phillips MD Perspectives of Chinese and Vietnamese Immigrants Article first published online: 17 JAN DOI: /j x

MORE TO READ ◊ Beth Ann Swan: A Nurse Learns Firsthand That You May Fend For Yourself After A Hospital Stay. Health Affairs, 31, no.11 (2012): dpo: /hlthaff ◊ Joe Tye (with Dick Schwab). The Florence Prescription. From Accountability to Ownership. Copyright 2009, 2014 by Joe Tye ◊ John Kenagy, MD, MPA, ScD, FACS Designed to Adapt. Leading Healthcare in Challenging Times. Second River Healthcare Press, 26 Shawnee Way, Suite C, Bozeman, MT

References ◊ ND Long Term Care Association (NDLTCA) - Economic Pulse Report 2012 ◊ ND Hospital Association (NDHA) – Economic Pulse Report 2012 ◊ An Environmental Scan of Health and Health Care in North Dakota: Establishing the Baselines for Positive Health Transformation. March 2009 ◊ Rural Care Coordination Toolkit. Webiinar : Care Coordination in Rural Communities. recorded February 12, 2014 ◊ Lin Grensing-Pophal: Leading when You’re Not the Formal Leader. Advance Healthcare Network for Nurses. April 2, 2014 ◊ Actuarial Report on the Financial Outlook for Medicaid. Report to Congress Reimbursement/Downloads/medicaid-actuarial-report-2013.pdf

THE NURSE PULLS IT ALL TOGETHER
Fantastic tree in Italy.

And so we move into the Change & Innovation module
Wrap-up Reflect on the complexity of the overall healthcare system Reflect on your organization within the system Reflect on your position within your organization Reflect on the result of your patient advocacy experience How could a different reality make your experience more successful and satisfying? What will you do to move toward that different reality? And so we move into the Change & Innovation module

EMPOWERING NURSES TO LEAD

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