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Safe Transitions Of CareSTOC2011
MHA Pilot- 4Q 2010
Transition responsibility belongs to the sending clinician/organization,
until the receiving practitioners confirm assumption of responsibility
Learning Objectives
1. Explain 2 reasons why safe transitions of care is important.
2. List the 4 metrics Fairview Northland has chosen to monitor in 2011, and our performance goal.
3. Explain your role and responsibility in this process.
Why is Northland participating?
Safety – safe patient hand-off, self care
Satisfaction- pt/family, partners
Cost- readmission
Mission- Patients 1st , Community Health, Clinical Quality
Transitions = Hand-Off Transferring Facility Contact Person Phone # Fax # Receiving Facility Contact Person Phone
# Fax # Primary & Secondary Diagnosis Problem List Allergies Falls Risk Infection/Isolation Mental Status Behavior Status Pain Assessment Skin Assessment Communication needs Code Status Goals- Overall Progress Immediate FU Needs-
procedures/lab/tests Special Diet DC Medications Labs Last 24 hrs pertinent test results &
pending
Core Elements
Receiving facilities complained they did not have crucial information &/or could not easily locate it (multiple pages).
Satisfaction: Discharge
In your opinion, was the patient and family satisfied with the transition process?
In your opinion, were staff at the receiving facility satisfied with information communicated during the transition?
Critical to Success: Response time = now Satisfy every request in one call Anticipate needs during prep
Critical to Success: Response time = now Satisfy every request in one call Anticipate needs during prep
Cost: Readmission Frequency
12 month period, 4Q 2009 – 3Q 2010
Northland is lower than QUEST best practice peer group
Mission: Community Reputation
Transition Stories Make a Difference
Every Transition Is a Story In the Making
Inpatient Satisfaction- 2010
Performance Measurement- Review
What’s Important?Each Patient Transfer has a 4 point
opportunity, each pass/fail.
1 point = All Core Elements addressed in transfer information
1 point = Receiving facility scores satisfaction as positive
1 point = Family/patient satisfaction is positive
1 point = Patient not readmitted within 30 days of discharge
How is it Reported?
5 = Greater than or equal to
80.0% 4 = 70.0 - 79.9 3 Target = 58.0 -
69.9 2 = 50.0 - 57.9 1 = Less than or equal to
49%
Your Role- Discharge Prep
Social Workers
• Investigate SNF bed options when probability is d/c to NH
• Obtain bed placement when final discharge plan communicated
• Write DC date on white board in patient room
• Coordinate discharge time with RN Care Manager & Charge Nurse
• Determine transportation and pick up time
• Write pick up time on white board in patient room
• Communicate pick up time via pager to charge nurse/care manager
• Determine LOS/approximate date of discharge • Notify care team of discharge date and treatment plan• Complete discharge orders in EPIC• Sign orders electronically• Complete Discharge summary
Hospitalists
Your Role- Discharge Prep
Charge Nurse
• Obtain notification of discharge date/time via interdisciplinary care team• Review discharge orders and medication reconciliation for accuracy and
completeness• Verify that medication orders have NOT been sent to local pharmacy• Communicate readiness of patient for transfer to Nursing Station Attendant when
discharge checklist is complete and information is available to fax
• Obtain notification of discharge date/time via interdisciplinary care team• Complete discharge navigator/discharge profile• Communicate completion of patient profile within discharge navigator to
charge nurse• Complete verbal report to NH staff prior to patient leaving facility• Prepare the patient for discharge• Complete all discharge documentation via discharge navigator
Case ManagerRN
• Fax After Visit Summary and Medication Orders after notification of readiness by Charge Nurse- DO NOT FAX until “green light” from charge nurse.
• Place After Visit Summary and all other documents in transfer envelope
• Follow-up appointments??
NSA
Performance Measurement
What’s Important?
Each Patient Transfer has a 4 point opportunity
1 point = All Core Elements addressed in transfer information
1 point = Receiving facility scores satisfaction as positive
1 point = Family/patient satisfaction is positive
1 point = Patient not readmitted within 30 days of discharge
Social WorkerResponsibilities
24 hours after transfer – our FN Social Worker contacts the nursing home SW to inquire about patient/family satisfaction.
Satisfaction is indicated on a 5 point scale
CN section of the form not shown
Charge NurseResponsibilities
Prior to releasing the patient, complete the Discharge Checklist.
All Core (required) element must be included.
Performance Results/Reporting
Initial Performance Data- February 2011
Clinical Practice DirectorReceives & Reviews all casesQuality DirectorScores and Reports graph/dataSent to your manager
RESULTS- Progress to Goal• January = 71%• February = 76%
Opportunity for improvement: • Improve Core Element communication
Are we able to do More?
Project RED
1. “Teach-back” methods2. End of Life plans3. Multidisciplinary care
coordination4. Transitional Care Model5. Comprehensive DC Plans6. Schedule FU appointments7. Coach- Med Management
What do you think?
During Hospital - Discharge - Post Discharge
8. Home visit9. Call Back & FU10. Maximize My Chart (PHR)11. Community Networks
(websites)12. Telehealth monitoring (eICU)