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COMMUNITY PARTNERSTRANSITIONS IN CARE UPDATE2014 Q1
Project Outline
Open lines of communication Variations in Requirements for
Facilities Loop closure:
Physician input for patient care
Project Outline Structure
INTERNAL
EXTERNAL
Transitions Teams Composition Internal Team
Kim Lawson Medical Surgical Nursing Director Jody Gregory Critical Care Director Christi Cook Case Management/Social Work
Director Michelle Nelson Ambulatory Services Director Cindy Hoff Performance Improvement
Coordinator
External Team Leaders Robin Moreno- External Team Steering Group and
Focus Groups facilitator
Mark Koch- NH/SNF Focus co leader
Linda Foley- NH/SNF Focus co- leader
Shelby Crabtree- Hospice focus group leader
Susan Chavez- Home Health focus group co leader
Becki Hamilton- Home Health focus group co leader
Karla Dwyer- LTACH/Rehab focus group leader
Roddy Atkins- Mental Health focus group leader
Project Outline
Description of Team Integrations Team Collaboration What is the Purpose and expected
outcomes? AIM Statements
AIM Statements
1. To Identify high risk patients and create a handover process to provide support to community partners
2. Decrease 30 day All Cause Readmission by X%TBD
3. Improve Patient Satisfaction Scores on HCAPS Discharge question by 2% over previous year.
4. Increase Knowledge of health care providers in optimizing the handover process to prevent gaps in care transitions and adverse events.
Today we will:
1. Review progress of external and internal care transition teams
2. Identify next steps with the teams
3. Provide update on discharge and readmission process
External Teams Update
Community Partners External Groups Home Health- North Texas and First Texas leading group.
Meeting every two weeks; Tuesdays 330-430pm. LTACH/Rehab- HealthSouth and Texas Specialty leading group. Meeting PRN basis. Nursing Homes/SNF-. Monterrey and Senior Care leading group. Meeting every other Wed 2pm. Hospice- HOWF leading group. Meeting monthly. Tue 4pm. Mental Health- Helen Farabee leads group. Focus: Develop Resource Directory and Mental Health First Aid Card. Meeting monthly. ALF’s-First meeting Nov 27th. Leaders: TBD Meeting: TBD PCP, Onc’s, CNT, CHC, Incompass, Ambulatory Physicians- Will not meet until groups have identified issues and worked thru corrective processes.
Facilitator: Robin Moreno, MHA-HSA
BOOST Implementation Timeline
Planning Phase Activities:1-3 months August-November 2013
During planning phase, focus groups addressed:Review of BOOST manual, processes, meeting goals, 8p’s, GAP analysis Baseline assessmentsSWOT analysisFMEA process(variation of) and ID top three issues to address
Implementation Phase Activities:4-6 months December 2013- February 2014
Intervention Phase Activities:7-10 months March-May 2014
Project Surveillance & Management :10-12 months June- August 2014 Facilitator: Robin Moreno, MHA-HSA
External Team Next Steps
Develop the Physician/PCP Team and align with existing internal/external team outcomes
Evaluate additional patient populations requiring special consideration, i.e. Homeless/Shelter
Internal Team
1. Teach Back Education2. 8P’s Assessment Form3. Discharge Medication List 4. Discharge Binder
Internal Team Next Steps
1. Rapid Cycle Trial of Nurse to Nurse Report
2. Develop Discharge Checklist incorporating areas identified in 8P’s
3. Create a discharge communication tool in the EMR utilizing info from the BOOST Gap assessment and discharge checklist tools.
Post Acute Care Discharge Follow up
1. Heart Failure Phone Calls/Zone Cards
2. Heart Failure Clinic
3. Diabetic Phone Calls/Zone cards
4. Diabetic Education/Nutrition Referral Process
Post Acute Discharge Follow up Next Steps
1. Pulmonary/COPD Discharge phone calls/Zone cards
2. Stroke Discharge Follow up process
Discharge Planning Update
Discharge/Resource Center Process
Readmission Case Review and Follow up process
Standard Referral Information
History & Physical All consults PT/OT/ST notes In-hospital Medication List – NOT THE
DISCHARGE MED LIST Lab results
Special Occasion Information
Vital signs Respiratory info Swallow study Assessment and interventions I & O Nutritional documentation
Discharge Information
Discharge med list Copy of physician progress notes IF TO HOME HEALTH Patient education Patient instructions
Discussion/Q&A
Contact Info:
Michelle Nelson 764-6714Christi Cook 764-3095Robin Moreno 322-1672 Kim Lawson 764-3637Jody Gregory 764-3868Service Desk/IT Helpline 764-3242