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