INTERACT II November 2012

Your hosts: Jody Rothe, MetaStar Stephanie Sobczak, WHA

Thank you to these organizations for sponsoring this webinar series:

Acknowledgements

A special thank you to the Wisconsin Clinical Resource Center for serving as the home base for recorded webinars and materials related to the INTERACT II collaborative

INTERACT II July Overview & Case Review

ToolsAugust Communication ToolsSeptember Early Warning ToolsOctober Change in Condition ToolsNovember Resident Transfer ToolsDecember Continuous Improvement

Tools

Review 30 day Action Items & data update Discussion Share experiences with Change in Condition

Card and Care Path testing Review key Resident Transfer tools –

Transfer Checklist, Resident Transfer Form Working with Hospitals on Transfer Tools Implementing Transfer Tools 30 day Action Items

Today’s Agenda

What INTERACT II tools have you implemented?SBAR 78%Stop and Watch 75%Change in Condition 43%Care Pathway 32%  Are you able to keep up with monthly data

submission?Yes 57%No 43%

Results from Feedback Tool

What is most challenging about the INTERACT II program?

Joining webinars. 23%Obtaining materials from websites 3%Submitted data 30%Convening a staff team 36%Completing monthly action items 50%

Have you had interaction with your local hospital about care transitions?

Yes 63%No 43%

Results from Feedback Tool

Can anyone share what their agenda items were for discussion with hospitals or other care providing organizations?

Discussion

How does everyone have the right information at the right time to do what is right for the patient in the right setting?

Key Question about Transfers

1) Relies on very good communication between sites of care: Nursing Home Hospital Nursing Home

(The physician is the arrow in this diagram)

2) Relies on consistent processes in each of the sites:

Problem Identification, Documentation, Notification protocol need to be addressed consistently.

About Transfers – 2 issues

1. Standardized patient transfer forms?

2. Checklists for staff?3. Key personnel contact lists?4. Site capability assessment?

Communication between sites

1. Is there agreement on transfer criteria?

2. Is it possible to return patient to LTC from ER (without an inpatient admission)?

3. Expectations around the transfer process (i.e. patient transport)?

Consistent processes

Everyone in the care continuum is responsible for ensuring their processes in handling patient/resident transfer is the best it could possibly be.

Hospitals Primary Care Home Health Nursing Home Community Based Organizations

It’s not the people…it’s the process!

Continuous Improvement is a necessity between and within all sites.

Who is responsible for the handoff?

Resident Transfer Form Clinical Capability Inventory Acute Transfer Checklist

INTERACT II Tools

Resident Transfer Tools

What does each facility really need?

“Less is more”

Want information that is vital, and easy to find.

Can one tool be designed for all sites to use???

Resident Transfer Tools

Sit down with referral sources.

Talk about transfer that do well – how can you do more of that?

Share what your clinical capabilites are. (vents? I.V.s? PCA’s?)

Collect information on what is needed.

Review the process for transferring people and paperwork.

Bring everyone around the table

Will you use a template? ORDesign your own?

Who will be involved in testing the drafted transfer tool?

How will the feedback from those tests occur?

When will you know it is ready to adopt?

Key Decisions

Co-designing transfer tools

Guest speaker

Why would sharing your facilities capabilities be beneficial for your working relationship with the hospital?

Clinical Capability Inventory example

1. Hospitals know in advance if the patients needs are in line with your facilities capabilities.

2. Prevents re-work of “false start” admissions!3. Clarifies expectations between staffs and

physicians.

Clinical Capability Inventory

Resident Transfer Process

It can be very helpful to diagram the transfer of patients and information from one site to another

A simple diagram can be madeLong Term Care Resident Physician Hospital Acute Care Physician

Care plan indicates hospital transfer

Call Med Direct.

SBAR – update resident status

Resident Transfer Tools

INTERACT II TransferChecklist

This check list can be secured to outside of envelope which hold documents for the transfer.

Which of the following tools have you used in the past?

(Check all that apply)Facility capability tool Resident transfer toolAcute care transfer checklist

Poll Questions

Have you co-designed any of these with other provider entities in your community?

Are there any recommendations for testing these changes on a small scale before implementing?

Discussion

Poll AnswersWhich of the following tools have you used in

the past?(Check all that apply)Facility capability tool Resident transfer toolAcute care transfer checklist

Review the Resident Transfer Tools with Staff Have volunteer staff test the Resident

Transfer Tools through small tests Evaluate the tests Decide to adapt/adopt/abandon Submit data

Action Items for this Month

A Feedback Tool will be send after December 5th to assess your progress on these tasks.

Thank you!

See you next month

Next month: Continuous Improvement Tools