Pre meeting interactive learning carousel may-21_2015

Pre-Meeting: Interactive Learning Carousel

Station 1

Why are you here today?

Station 1: Why are you here?

I am here because I care about what I do and how I do it in transitioning individuals into community living.


To learn about resources for transitions


To learn more resources that are available for community transitions

Station 1: Why are you here today?

Planning to implement a lot with COPD (high risks + readmission). New ideas?


To learn and reflect-what do other people do that works well and I could do also?

To gain knowledge about transition resources avail


To learn + exchange ideas to share what tools we have + hopefully learn more to become better with transitioning people


Exchange ideas


Develop and/or learn innovative strategies. How are others doing it


Learn how to better coordinate successful transitions from SNF’s


To network


To increase my knowledge of resources for transitioning from program to another


Network and learn more about community


Hear more about resources program in NC


To learn as much as possible to better asst my patients


To better learn a cohesive path to ensure smoother transitions for care & to learn!


To gain more insight on the transition process, also possibly network with other transition team leaders, to also take back some info to my facility to better meet the needs of population I serve (complex patients)


To learn how to overcome obstacles in transition process


1. Interested in topics, i.e. Job/work 2. Increase referrals... for MFP


To learn more about transition planning, things I don’t already know, and learn from my peers


To become more effective as a transition coordinator


To increase my knowledge of comm resources


To hopefully learn ways/techniques to assist me when pts transition from one healthcare setting to the next


To learn more about resources available in the community for my residents who are discharging



To learn & share strategies that will allow for smooth transitions to home & reduce readmissions


Additional info on transition

How to better assess which patients are likely to successfully transition into the community


To learn new skills, to present, and meet others that have a shared interest in helping individuals with I/DD and Autism


To gain the skills necessary to lead individuals & other professionals into successful transitions


Learn and grow


To learn how D.C. Senior Services can play a role in

transitions


To learn resources to better assist community transitions



Learn, Share, Act


To gain better knowledge & resources for transitions

To learn as much about the MFP process, to be better at my job


To learn more info about the transition process


Interested in being part of conversation to address needs of folk transition


Learn about more resources for people who are transitioning, learn how to engage family & guardians


Try to update peers of incredible fast pace of hospital difficulty of stress


To hopefully bring back some good community resources that will help myself and my co-workers in our discharge planning


Learn how to break down barriers w/ transitions process


To grow professionally, to learn, to network


Learn others’ golden nuggets about best person-centered practices and applied to quality transitions into real community life


To put things in perspective


The potential to affect change


To be able to enhance my knowledge, improve our transitions care program, to expand in all care settings


Station 2

What facilitates (supports) transition efforts?

Station 2: What facilitates (supports) transition efforts?

Communities


Coordination


Supporting the person’s goals


Getting input from the person who is transitioning


Resources & referrals


What team members can do & what their agency can provide


Transition coordinator/agency developing strong collaborative partnership


Effective communication b/w community base providers & hospitals


Realistic expectations


Knowledge of sustainable supports


Collaborative work among agencies


Community effort-everyone on the same page working toward the same goal


Staying person-centered


Good action plan & someone they can call on


Open-minded, not imposing your belief values


Natural supports & invested team members


Supportive family


Primary care


Communication


Administrations that understand the process


A team of people who we can rely on! As a transition coordinator, I know some things- but need a good tam/network to ask questions


Team work among all players


Relationship and rapport with individual


Good communication between programs


Person being open to next level of care


Other professionals understanding the program (MFP, PACE)


The needs of the person needing transition care


A positive attitude from all team members so that the person can be successful


Teamwork and open communication


The attitudes of the care worker & the individual transitioning &

knowledge of care worker to resources available


Addressing barriers


Use of evidenced-based practices across the continuum


Referrals & coordinating with resources for a successful transition


Good communication, available resources, patient/family buy-in/support


Involvement of durable medical providers, such as respiratory post D/C


Strong support system “family, church, friends, neighbors”


Natural support, good plan developed with individual, monitoring and .... addressing barriers


Provider agencies, developmental centers & MCOs


Trust & relation support


Collaboration among supports


People who are willing to take risks!


Being a knowledgeable guide


Positive attitude, wanting to learn, avail resources, be realistic and honest


Consideration of the whole person and identifying best and worst scenarios and planning for the most support possible


Good action plan & someone they can call on

Station 3

What are the barriers (hinders) to transition efforts?

Station 3: What are the barriers (hinders) to transition efforts?

Lack of staff with base community resources


Issues with school systems not being tolerant


No placements available for adults/children that can meet needs. Providers saying they have availability, capability, experience but don’t


Lack of knowledge of what each level of care can provide among providers


Lack of communication or warm hand off to community-based providers, hospitalization


Occasional lack of transparency


Political will to remove all the barriers


Lack of knowledge on possible purchasing a home


Need for additional technology rest assured


Money within communities to provide resources & FTEs


Not identifying needs prior to discharge, i.e. equipment, financial capability to pay for medicines etc.


No funds available within the time needed for services trying to access


Lack of resources


Willingness of the person to apply for resources


Lack of resources, “transportation”, housing


Medicaid deductible


Categories of support: there are always people who fall thru the cracks, don’t qualify-we need to be creative about making sure they have needs met!


Limited ICF (intermediate care facility)

vacancies


No insurance, self pay


No primary care giver but trying to figure out how to access their rights


Lack of family/community support


Low income


Limited resources


Housing/criminal background before disability


Home repairs


Knowledge of resources, i.e. Home mod, housing


Organizational policies & procedures


Transitioning pts from home to SNF and haven’t seen MD in

months/years


Rural areas with limited resources especially

transportation


Rural areas (lack of resources)


Communications, lack of technology in home


Wait time-transition process takes too long and they get frustrated


Lack of housing/support systems


Unrealistic expectation of person, lack of acceptable understanding of medical needs


Lack of finances, community support, and options


Lack of community, family support


Hospital not aware of community partners (if person doesn’t tell

staff)


Patient + medical team not having same goals


Lack willing or capable caregivers


Lack of transportation


On-going criminal activities


Expectation from everyone involved


Not enough resources in my area, medics/Medicaid restrictions guidelines


Funding, lack of appropriate services, lack of insight, and motivation


Time frame for application approve assessment


Affordable/accessible housing, community-based personal assistant services, policy that limits individual choice


ACTT drift of mission over the years trying to partner, equip, encourage staff to join our “mission”

Station 4

Emerging principles

Station 4: Emerging principles

What resonates with you the most? What, if anything, is missing?


Work yourself out of a job


Be creative-outside box


Flexible


Crisis planning


If nursing home patient came from home that was not

safe/cannot go back


Optimistically honest


Resonates most, being optimistically honest-if people, family know, it’s better for them to plan


Assessment-building relationship


Optimistic honesty + education


Not chaotic or sluggish, keeping momentum going hard


Center is person & family


Participant in the middle (harder than it looks)


Individual is guiding the goals


Empowering person to take responsibility


Making LTC facilities know about transitions opportunities-for public too


Community-based services, housing, transportation, individual choice


Holistic perspective


Put everything in place


Warm hand offs


Collaborating with others


Relationship building with participant—family


Communication & other systems SS/DSS/AEC, etc.


Need to know continuity of resource knowledge & communication


Don’t have to be an expert in everything


Teamwork


Communication, funds, step out of the box, ...


There should be conversations with guardians/people about transition prior to making application. Sometimes when I come to initial meetings-the guardian/person has no idea why I am there and I have to awkwardly explain. There should be several initial conversations with the team prior to beginning the MFP process.


Tracking outcomes to provide evidence-based practices

Pre meeting interactive learning carousel may-21_2015

Education

Transcript of Pre meeting interactive learning carousel may-21_2015