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Home Health Partnership. A collaborative approach to reducing re-admissions. What’s wrong with this picture?. Each department may excel in their respective practice, but without communication and collaboration the outcomes may not turn out as anticipated. - PowerPoint PPT Presentation
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A COLLABORATIVE APPROACH TO REDUCING RE -ADMISSIONS
Home Health Partnership
What’s wrong with this picture?
Each department may excel in their respective practice, but without communication and collaboration the outcomes may not turn out as anticipated.
The Partnership between ValleyCare and Alliance Home Health Care
Ongoing exchange of patient centered information
Monthly round table meetings to gain insight into challenges, successes, improvement of practices
Telephone, Fax, and Email follow up on casesShared information between departments to
help develop new tools to facilitate continuity of care
Provides continuity and consistency in content once the patient returns to the community setting.
Using the same teaching materials in all patient settings
Daily Phone Call Follow-up between skilled nurse visits
Using agency specific forms
Identifies subtle changes in condition designed to prevent escalation of emergent care.
Provides succinct information to the physician to expedite orders or direction to the home health provider
CHF Alert Form
A communication tool for physicians who prefer written updates
Standard CHF Patient Report
INFORMATION EXCHANGE WITH CASE MANAGER AT INTAKE STAGE
AT START OF CARE (SOC) – ONE PAGE PHYSICIAN STANDING ORDERS FOR CHF
PROVIDED TO HOME HEALTH AGENCY (HHA)
THOROUGH REVIEW OF HISTORY AND PHYSICAL BY HHA INTAKE STAFF
CRITICAL INFORMATION, ORDERS PASSED ON TO HHA STAFF CARING FOR PATIENT
Handoffs
PHONE
FAX
IN PERSON AT CARE CONFERENCES, MEETINGS
SUPERVISOR STAFF REVIEW OF ALL DOCUMENTATION FROM ALL HOME
HEALTH DISCIPLINES FOR IMMEDIATE INTERVENTION IF NEEDED
Communication
Success Stories Patient discharged without
emergent care (38 days on service) and no re-admission
Patient/caregivers knowledgeable and compliant with lifestyle and behavior changes
Patient/caregivers knowledgeable of early intervention/prevention of exacerbation
Challenges
Non-complianceSeverity of diseaseCommunication challenges between
providers/ departments, between shifts/weekends
Anticipated Mutual Outcomes
Patients remain in the community independent with disease management by the end of episode of care (60 days) if needed.
Both providers have thorough knowledge of patient’s condition in real time.
Reduction of re-admissions
COMMUNICATION AND COLLABORATION ARE VITAL TO THE SUCCESS OF PATIENT
CARE FROM THE TIME THE PATIENT WALKS THROUGH THE DOOR OF THE
FACILITY UNTIL THE LAST CLINICIAN LEAVES THE PATIENT’S HOME
Take-away
ALLIANCE HOME HEALTH CARE, INC.12657 ALCOSTA BLVD. SUITE 155
SAN RAMON, CA 94583OFFICE: 925-275-9300
FAX: 925-275-9304
DOROTHY COFFEY, MSN, RN, CNLADMINISTRATOR/DPCS
DCOFFEY@ALLIANCEHHC.COM
Contact Information
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