Continuum of Care

Joanne Svogun (Team Advisor)

Michael Tassiello

Manisha Sheth

Yvette Carp

How Our Specific Area of Interest Was Chosen.Michael Tassiello

What We Have Determined So Far.

Manisha Sheth

What Needs to Be Done From This Point Forward.Yvette Carp

“What Is a Continuum”?

Continuum Examples

McDonalds Drive Thru

U.S. Highway System

Initial Definition

Some patients may not flow through the entire continuum of care, resulting in a decrease in revenue and patient satisfaction

Entire Continuum

More Manageable

Goal #1 Determine Which Point in the Continuum to Address

How Do We Get From This

To This

How Our Specific Area of Interest Was Chosen.

We Needed a Flowchart to Help Us Better Understand the Present Hospital Continuum.

What If My Daughter Swallows a Rubber Frog?

ICU/CCU OR TELE Floors

ED Direct

6th Floor 7th Floor 8th Floor

Disposition

8-West ECFHome

What Will Be Our Target Area to Examine Within the Rehab Portion of the Continuum.

What happens to patients who leave 8W (inpatient rehab).

Where do they go?

Where Do Patients Go Post 8 West Rehab 44 % (107) home with home care 16 % (40) ECF 16 % (39) home with ACRM 11 % (28) other 5 % (13) home w/ other outpatient 5 % (12) home no services

Where Do Patients Go Post 8 West Rehab

0

20

40

60

80

100

120

Homewith home

care

ECF Home-ACRM

Other home-other

outpatient

Home-noservices

ECF-Extended Care Facility

0

5

10

15

20

25

honey hill waveny mediplex

Our Refined Definition

Due to a lack of formal affiliations with area homecare agencies, patients discharged from inpatient rehab to home care may not flow through the entire continuum of care, resulting in a decrease in revenue and customer satisfaction.

Home With Home Care

0

5

10

15

20

25

30

35

40

45

Nursing andHome care

CT-VNA H+ HomeCare

Home care agencies

Timeline

Goal #2 determine reason for loss to continuum- Mid - May 2005.

Goal #3 all changes implemented - July 2005.

Goal #4 monitoring 3 months post changes – Oct 2005.

What Have We Determined So Far.

8-West

ECFOther

Hospital/Floor

Home

WithHome Care

Services

WithOut-PatientServices

WithNo Services

How many were able to go directly home from 8W

72% of patients were able to go directly home from 8West Rehab.

8W Discharges to 2 Target Agencies (April – Oct 2004).

38

1822

10

0

5

10

15

20

25

30

35

40

N+HC CT-VNA

TotalPatients

Total @ACRM

Total %Lost

56% or 20 Patients Lost in

The Continuum

53% or 12 Patients Lost in

The Continuum

Why Were Patients Lost to the Continuum? Did Not Need Outpatient Services Did Not Obtain Outpatient Service

Despite a Need for Them Went Elsewhere (and Most

Importantly Why?

Goal #2 determine reason for loss to continuum Meetings and interviews with:

CT-VNA Nursing and Home care

Interview Patient: Who did NOT go to ACRM Outpatient Who DID go to ACRM

Meetings and interviews with 8 West Staff

Meeting With Home Care Agencies Discussion

A need for W-10 form faxed directly to themNeed to know patients functional levelMedicationsDiagnostic lists

Meeting With Home Care Agencies …contd In service:

N+HC Staff meet on the 3rd Thursday of each month. Willing to meet with our rehab team on occasion.

Communication & Education: Interested in our therapists discussing goals,

treatment strategies and discharge dispositions for common patients.

Progress toward Goal 2

Interviewed past inpatient rehab patients who did not go to ACRM outpatients, post home care services.

Results

Patient were NOT always aware of the need and availability of out patient therapy.

Not aware of benefit from a physiatrist consult. Ortho patients are often seen by there own

surgeons and rehab teams. Few patients go to community based wellness

programs.

Interview with patients who went to out patient ARCM

Interview 8 west staff

Discuss discharge instructions

What Needs to Be Done From This Point Forward.Yvette Carp

8 west inpatient staff

In service

Patient/caregiver education

Handouts

Home care agencies

Periodic Meetings & Education to follow through the continuum.

Implement all changes as determined by our data

Goal #4 – Evaluate the effectiveness Survey patients for their feedback Survey Home Care Agencies Follow up audit of post changes being

implemented within three to six months

If our changes help us capture 10% more of the patient lost to the continuum Increase Revenue = Number of patients

x

Av. Reimbursement

Can this information be utilized throughout the organization.

Marketing our ideas to make the continuum of care more efficient

In houseOutside hospital