IHI Expedition. Reducing Readmissions by Improving Care Transitions Session 2. Expedition Coordinator
|
|
- Luke Waters
- 6 years ago
- Views:
Transcription
1 Thursday, June 20, 2013 These presenters have nothing to disclose IHI Expedition Reducing Readmissions by Improving Care Transitions Session 2 Peg Bradke, RN, MA Saranya Loehrer, MD, MPH Expedition Coordinator 2 Kayla DeVincentis, CHES, Project Coordinator, Institute for Healthcare Improvement, currently manages web-based Expeditions and the Executive Quality Leaders Network. She began her career at IHI in the event planning department and has since contributed to the State Action on Avoidable Rehospitalizations (STAAR) Initiative, the Summer Immersion Program, and IHI s efforts for Medicare-Medicaid enrollees. Kayla leads IHI s Wellness Initiative and has designed numerous activities, challenges, and educational opportunities to improve the health of her fellow staff members. In addition to implementing the organization s first employee health risk assessment, Kayla is certified in health education and program planning. Kayla is a graduate of Northeastern University in Boston, MA, where she obtained her Bachelors of Science in Health Science with a concentration in Business Administration. 1
2 WebEx Quick Reference 3 Welcome to today s session! Please use chat to All Participants for questions For technology issues only, please chat to Host WebEx Technical Support: Dial-in Info: Communicate / Join Teleconference (in menu) Raise your hand Select Chat recipient Enter Text When Chatting 4 Please send your message to All Participants 2
3 Expedition Director 5. Saranya Loehrer, MD, MPH, Director, Institute for Healthcare Improvement (IHI), aligns care transitions related programming within IHI and provides coaching and facilitation to teams within the STAAR initiative. She also contributes to IHI s efforts to adapt promising practices to better care for Medicare- Medicaid beneficiaries and serves as one of IHI s content curators to ensure IHI s publications and resources are reflective of the most recent innovations and best practices in the field. Saranya received her medical degree from Loyola University Chicago s Stritch School of Medicine and her Master of Public Health degree from the Harvard School of Public Health, where she served as a Zuckerman Fellow. Today s Agenda 6 Action Period Report Out Content: Capturing the Patient Story Content In Action St. Luke s Hospital UCSF Medical Center Action Period Assignment 3
4 Overall Program Aim 7 The aim of this Expedition is to share strategies for hospitals and their cross-continuum partners to co-design care processes to improve the transition of patients from the hospitals to the next care setting. Expedition Objectives 8 At the end of the Expedition each participant will be able to: Assess current challenges in reducing avoidable rehospitalizations and identify opportunities for improvement Explain how to build an effective improvement team including patients and families as well as acute, post-acute and community care providers Describe how to use the patient story to build an individualized plan of care. Use appreciative inquiry and Teach Back to better understand a patient s post-acute care needs and capabilities Develop processes with post-acute care providers and community partners to ensure the timely transfer of critical information during patient transitions 4
5 Schedule of Calls 9 Session 1 Building the Team You Need to Reduce Readmissions Date: Thursday, June 6, 12:00-1:30 PM ET Session 2 Capturing the Patient Story Date: Thursday, June 20, 12:00-1:00 PM ET Session 3 Assess for Success: Appropriate Post-Acute Follow-up Date: Thursday, July 11, 12:00-1:00 PM ET Session 4 Passing the Baton: The Handover of Critical Information Date: Thursday, July 25, 12:00-1:00 PM ET Session 5 Putting it All Together: Orchestrated Testing and Implementation Date: Thursday, August 8, 12:00-1:30 PM ET Faculty 10 Peg M. Bradke, RN, MA, is Director of Heart Care Services at St. Luke s Hospital in Cedar Rapids, Iowa. She received her Bachelor s Degree in Nursing from Mount Mercy College and her Master s Degree in Nursing Administration from the University of Iowa, College of Nursing. In her 25- year career, she has had various administrative roles in the cardiac care areas. She currently coordinates the Heart and Vascular Service line which includes two intensive care units, two step-down telemetry units, the Cardiac Cath Lab, Electrophysiology Lab, Diagnostic Cardiology, Vascular and Interventional Lab, Respiratory Care, Cardiopulmonary Rehabilitation and Heart Failure and Coumadin Clinics. In addition, Peg is serving as faculty with the Institute for Healthcare Improvement (IHI) on the Transforming Care At the Bedside (TCAB) Initiative and STAAR (STate Action on Avoidable Rehospitalizations Initiative). 5
6 Action Period Report Out Reach out to 2 potential CCT partners to assess the current process for transfer of information Call 2 patients or caregivers hours after they have returned home to learn what went well and identify opportunities for improvement Some questions to consider: What has been your greatest concern since you went home? Did we miss anything in your discharge instructions? Were you confused by any of the instructions you were given? Now that you are home, what would you tell us is the most important thing we could have done for you to prepare you for your care at home? Action Period Report Out Continued What did you do? What surprised you? What will you do next as a result? 6
7 13 Capturing the Patient Story Peg Bradke, RN, MA Capturing the Patient Story Involve the patient, family caregiver(s), and community provider(s) as full partners in identifying the patient s home going needs. 7
8 Partner with Patient and Family to Determine Post-Hospital Needs Typical Failures Excluding the patient and family caregivers in assessing needs, identifying resources, and planning for discharge, leading to poor understanding of the patient s capacity to function in the home environment Lack of probing around unrealistic patient and family caregivers optimism to manage at home Lack of understanding of the patient s functional ability, ability to Teach Back, physical and cognitive health status, and social and financial concerns, which results in transfer to a care setting that does not meet the patient s needs 8
9 Partner with Patient and Family to Determine Post-Hospital Needs Typical Failures (cont.): Not addressing the whole patient (e.g., focusing on one condition, missing underlying depression, social needs, etc.) Not addressing palliative care or end-of-life issues, including advance directives or planning beyond Do Not Resuscitate (DNR) status Medication errors, polypharmacy, and incomplete medication reconciliation Labeling the patient as noncompliant and not recognizing the care team s responsibility for facilitating self-care management Ongoing Assessment of Post-Hospital Needs Transformational Change Ideas: Take 5 establish a relationship and build trust Nurses and members of the care team take a stance of appreciative inquiry or as an investigative reporter - Ask the 5 Whys 9
10 5 Whys Root Cause Analysis 5 Whys Root Cause Analysis no $ for meds no insurance unintended consequences of receiving Medicaid no application/medicaid needs helps with application 10
11 Open Ended Questions to Ask the Patient and Family Caregivers How do you think you became sick enough to come into the hospital? How do you take your medicines at home? Any problems? Any side effects? Describe your typical meals at home or at a restaurant. When did you last talk with your doctor or nurse? What did you talk about? What, if anything, worried you before you came to the hospital? Expanding the Focus of Daily Patient Care Rounds Develop one comprehensive assessment of patients postacute care needs that integrates input from all members of the care team Make sure each member of the care team is clear about what information they must bring to rounds each day Change the focus on daily patient care rounds to include a dual focus of optimizing care in the hospital and decreasing the length of stay while simultaneously planning to meet the post-discharge care needs of patients 11
12 Proposed Agenda for Patient Care Rounds What are the goals/reasons for this admission? Are the health care teams goals and the patient s and family caregiver s goals in sync? What needs to happen during this hospitalization? What are the criteria for discharge readiness? What post-acute care plan should be put in place to meet the patients (or family caregivers) level of activation and comprehensive of the discharge plans? Routinely ask the question what is the likelihood that this patient will be readmitted in the next 30 days? If the likelihood is high, why? What services can be put in place to mitigate potential problems? Example: Additional Information that Bedside RNs Should Bring to Daily Patient Care Rounds Ongoing assessment of comprehensive discharge needs (not solely on admission) Assessment of patients and/or family caregivers understanding of the post-discharge plans and selfcare (using Teach Back) Answers from patient and family caregiver to the following question What concerns or worries you the most about going home or to the next care setting? 12
13 What Are We Learning About Capturing the Patient Story? Initial assessment should be completed upon admission, but ongoing assessment of homegoing needs should be ongoing over time Most teams think that they are already doing the assessment -- but have gained new insights from completing the diagnostic reviews Teams should consider embedding questions from the diagnostic review into the admission assessment for patients What Are We Learning About Capturing the Patient Story? Family caregivers and community providers are a vitally important source of information about home-going needs of patients There is often a discrepancy between the patient s, the family caregiver s, and provider s perception of the patient s needs and capabilities Completing a comprehensive admission assessment requires additional time; roles and responsibilities need to be designated and standard work processes need to be developed Multidisciplinary rounds are important to build the patientand-family-centered story and establish a comprehensive post-hospital plan of care 13
14 Aimee Traugh & Diane Pfeiler 28 Content in Action: St. Luke s Hospital Aimee Traugh Diane Pfeiler 14
15 ST. LUKE S HOSPITAL MEMBER, UNITYPOINT HEALTH SYSTEM Private hospital Cedar Rapids, Iowa Affiliate of UnityPoint Health System Licensed for 500 Beds with more than 17,000 admissions Truven Top 100 Hospital 5 years (2013); Heart Hospital 3 years (2012) Iowa Recognition for Performance Excellence Gold Award 2010 Magnet Designation 2009 Joint Commission Disease Specific Certification in Advanced Heart Failure, Stroke, Palliative Care and Total Joint. Society of Chest Pain Center Chest Pain Certification Gold Award from Get with Guidelines for Heart Failure UNITY POINT-ST LUKE S 3 CENTER BEDSIDE HUDDLES Putting patients at the center of all we do! 15
16 HUDDLES AS WE KNEW THEM Primary nurse, charge nurse, care coordinator Occurred at the nurse s station Multiple interruptions Noisy, noisy, noisy! Something was missing oh yeah, the patient! STAFF ENGAGEMENT Discussed at Unit Planning Committee Jan 2013 Decision made by frontline staff Dissemination of plan through weekly newsletter Focus on patient-centered care Manager support during implementation phase starting February 4 th
17 HUDDLES AS WE KNOW THEM NOW Occurs at patient s bedside with patient/family input Charge nurse guides intent daily goals, discharge goal, fall risk, skin integrity risk, Primary nurse daily goals to white board, barriers to discharge identified Care Coordinator opportunity to lay eyes on every patient, learn barriers, discuss discharge plan Documentation specialist listener, captures undocumented severity of illness, risk of mortality Maureen Carroll, RN, CHFN 34 Maureen Carroll, RN, CHFN, has been a clinical nurse on the cardiovascular unit at the University of California San Francisco since While working at UCSF she became a Geriatric Resource nurse, certified through the American Association of Heart Failure Nurses, and is currently working on a Master s degree at Regis University. Maureen has been the Heart Failure Program Coordinator at UCSF since October Maureen has developed and led the multidisciplinary Heart Failure team, the Readmissions Task Force at UCSF, and achieved the goal of reducing readmissions for heart failure patients by 30%. Maureen has presented at the Institute for Healthcare Improvement Annual Forum in 2010 and 2011, the University Health Care Consortium, and for the American College of Cardiovascular Administrators. She has consulted with many hospitals while working with the Avoiding Readmissions Through Collaboration (ARC) group and continues to work full time as the Heart Failure Program Coordinator at UCSF as well as faculty with the Institute of Healthcare Improvement. 17
18 35 Content in Action: UCSF Medical Center Maureen Carroll RN, CHFN UCSF Multidisciplinary Rounds Maureen Carroll RN, CHFN Heart Failure Program Coordinator 18
19 Background on MDR The evolution of MDR on one Cardiovascular unit What led to recent changes? Challenges Many Four cardiology teams, CT Surgery, & Vascular teams that we need to get report from daily New Residents every month Getting the entire team together at one time Getting the patient s story into rounds Busy and loud Nurse s station where rounds were held Not enough room for everyone Could not hear Privacy issues 19
20 Multidisciplinary Rounds -- Before What Changes Were Needed for Improvement? New location -Quiet, large enough for large Multidisciplinary Team, privacy Ongoing communication to new Residents each month Leadership approval Continuity Patients stories retrieved and communicated 20
21 MDR- What is the Goal? Addressing each patient s situation and communicating the needs and the plan between all disciplines involved What is the overall clinical picture of the patient and what will be needed for an optimal discharge? What are the psycho-social needs and /or concerns of this patient? (i.e. cognitive deficits, low health literacy, illiterate, support needs, financial concerns, etc.) What is the patient story? Is this patient considered at high risk for readmission? (Response to clinical condition, number of readmissions in past year, ability to manage chronic condition, ability to Teach Back, history that may affect outcomes, adherence to medication regimen, etc.) MDR - Goals What consults will benefit this patient on this admission? (dietary, spiritual, pharmacist, social worker, etc.) What are the appropriate support options for this patient? (RN/OT/PT Home care services, specialty clinic appointments, MD home visits, serial follow up calls, etc.) 21
22 The Patient Story Bedside nurse brings patient story to the Charge Nurse who attends MDR daily PM Charge Nurse communicates with AM Charge Nurse Case Manager meets with patients and families with any potential needs Chaplain meets all patients and families - attends rounds Heart failure coordinators meet with HF patients and families Residents add clinical story and needs Social worker meets patients and families with identified needs RESULTS= The Story is pieced together as a Team Multidisciplinary Rounds -- After Quiet, private area Comprehensive team addressing patient s needs Next steps in care Readmission risk Next goal: Include the Pharmacist 22
23 Action Period Assignment Observe rounds/huddles where patient transitions are discussed and think about the following: Who attends them? How are the patient s post-discharge needs surfaced and discussed? How are the perspectives of the clinical team solicited and incorporated? How are the patient s post-discharge needs addressed? Based on what you learned, what might you test to improve your process? Chat Time! 46 Chat in one thing you learned during today s session
24 Expedition Communications 47 Listserv for session communications: To add colleagues, us at Pose questions, share resources, discuss barriers or successes Next Session 48 Thursday, July 11, 12:00 PM 1:00 PM ET Session 3 Assess for Success: Appropriate Post- Acute Follow-up 24
IHI Expedition Reducing Readmissions by Improving Care Transitions Session 4
Thursday, July 25, 2013 These presenters have nothing to disclose IHI Expedition Reducing Readmissions by Improving Care Transitions Session 4 Peg Bradke, RN, MA Saranya Loehrer, MD, MPH Expedition Coordinator
More informationEnhanced Assessment for Post Hospital Needs
These presenters have nothing to disclose Enhanced Assessment for Post Hospital Needs Maureen Carroll September 28, 2015 Session Objectives Participants will be able to: Identify failures in current processes
More informationReducing Readmission Case Stories Discussion of Successes
Reducing Readmission Case Stories Discussion of Successes University of California, San Francisco Maureen Carroll RN, CHFN Transitional Care Manager Heart Failure Program Coordinator UnityPoint Cedar Rapids
More informationIHI Expedition. Reducing Readmissions by Improving Care Transitions Session 1. Expedition Coordinator
Thursday, June 6, 2013 These presenters have nothing to disclose IHI Expedition Reducing Readmissions by Improving Care Transitions Session 1 Peg Bradke, RN, MA Saranya Loehrer, MD, MPH Expedition Coordinator
More informationIHI Expedition. Improving Patient Experience and Making It Stick Session 5. Expedition Coordinator
Wednesday, August 21, 2013 These presenters have nothing to disclose IHI Expedition Improving Patient Experience and Making It Stick Session 5 Barbara Balik, RN, EDd Kelly McCutcheon Adams, LICSW Expedition
More informationWebEx Quick Reference
IHI Expedition: Effective Implementation of Heart Failure Core Processes Peg Bradke, RN, MA, Faculty Christine McMullan, MPA, Director December 15, 2011 These presenters have nothing to disclose WebEx
More informationM7: Improving Transitions and Reducing Avoidable Rehospitalizations. St. Luke s Hospital Member, Iowa Health System
M7: Improving Transitions and Reducing Avoidable Rehospitalizations Peg M. Bradke, RN, MA St. Luke s Hospital, Cedar Rapids, Iowa This presenter has nothing to disclose. St. Luke s Hospital Member, Iowa
More informationRhonda Dickman, RN, MSN, CPHQ
Rhonda Dickman, RN, MSN, CPHQ Rhonda Dickman is a Quality Improvement Specialist with the Tennessee Hospital Association s Tennessee Center for Patient Safety, supporting hospitals in their quality improvement
More informationDeveloping Post- Hospital Follow-Up Care Plans and Real-time Handover Communications Peg Bradke
These presenters have nothing to disclose Developing Post- Hospital Follow-Up Care Plans and Real-time Handover Communications Peg Bradke September 28, 2015 Session Objectives Participants will be able
More informationExpedition: Improving Safety and Reliability for Surgical Procedures
These presenters have nothing to disclose Expedition: Improving Safety and Reliability for Surgical Procedures Session 5 William Berry, MD, MPA, MPH, FACS Kathy Duncan, RN January 23, 2014 Expedition Coordinator
More informationCareTrek : Nebraska s Journey to Safe Care Transitions
CareTrek : Nebraska s Journey to Safe Care Transitions Audrey Paulman, MD, MMM Principal Clinical Coordinator CIMRO of Nebraska This material was prepared by CIMRO of Nebraska, the Medicare Quality Improvement
More informationCommunity Care Coordination Cross Continuum Care IHC Medical Home Conference September 5, 2012 Des Moines IA
Community Care Coordination Cross Continuum Care IHC Medical Home Conference September 5, 2012 Des Moines IA Peg Bradke, RN, MA Director of Heart Care Services St. Luke s Hospital, Cedar Rapids, IA Session
More informationIHI Expedition. Improving Care for Frail Older Adults with Complex Needs Session 3
Wednesday, October 30, 2013 These presenters have nothing to disclose IHI Expedition Improving Care for Frail Older Adults with Complex Needs Session 3 Joanne Lynn, MD, MA, MS Holly Stanley, MD Karen Baldoza,
More informationIHI Expedition. Antibiotic Stewardship Session 2: Promoting a Culture for Optimal Antibiotic Use. April 3, Diane Jacobsen, MPH Loria Pollack, MD
April 3, 2014 These presenters have nothing to disclose IHI Expedition Antibiotic Stewardship Session 2: Promoting a Culture for Optimal Antibiotic Use Diane Jacobsen, MPH Loria Pollack, MD Today s Host
More informationEffective Care Transitions to Reduce Hospital Readmissions
Effective Care Transitions to Reduce Hospital Readmissions November 8, 2017 Anchorage, Alaska The vicious cycle of readmissions What is Care Transitions? The movement of patients across settings, referred
More informationL19: Improving Transitions from the Hospital to Post Acute Care Settings
This presenter has nothing to disclose L19: Improving Transitions from the Hospital to Post Acute Care Settings Gail A. Nielsen December 8, 2013 25th Annual National Forum on Quality Improvement in Health
More informationThe STAAR Initiative
The STAAR Initiative Getting Started Kit for the STAAR Collaborative September 2010 Institute for Healthcare Improvement, 2010 Page 1 Table of Contents STAAR Collaborative Charter... 3 Statement of Need...
More informationToday s Host 2/18/2016
February 18, 2016 These presenters have nothing to disclose IHI Expedition Improving Care Transitions To Reduce Readmissions Session 2: Establish and Implement a Person Centered Transition Plan to meet
More informationCareTrek : Nebraska s Journey to Safe Care Transitions
CareTrek : Nebraska s Journey to Safe Care Transitions Audrey Paulman, MD, MMM Principal Clinical Coordinator CIMRO of Nebraska This material was prepared by CIMRO of Nebraska, the Medicare Quality Improvement
More informationQuestion Patient #1 Patient #2 Patient #3 Patient #4 Patient #5 Number of days between the last discharge and this readmission date?
Worksheet A: Chart Reviews of Patients Who Were Readmitted Conduct chart reviews of the last five readmitted patients. Reviewers should be physicians or nurses from the hospital and community settings.
More informationTRANSITIONS of CARE. Francis A. Komara, D.O. Michigan State University College of Osteopathic Medicine
TRANSITIONS of CARE Francis A. Komara, D.O. Michigan State University College of Osteopathic Medicine 5-15-15 Objectives At the conclusion of the presentation, the participant will be able to: 1. Improve
More informationIHI Expedition. Today s Host 9/17/2014
September 6, 204 Begins at 3:00 PM EST These presenters have nothing to disclose IHI Expedition Expedition: Appropriate Use of Blood Products Session 3: Transfusion Safety Program Infrastructure: Measures
More informationIHI Expedition: Smart Use of Resources: Nurses' Time. IHI Support Staff
IHI Expedition: Smart Use of Resources: Nurses' Time Session 6 June 28, 2012 Content: Designing new care delivery models IHI Support Staff Tracy Jacobs Director Kayla DeVincentis Project Coordinator 2
More informationIHI Expedition Protecting Your Patients from Injurious Falls Session 4
March 13, 2013 These presenters have nothing to disclose IHI Expedition Protecting Your Patients from Injurious Falls Session 4 Pat Quigley, PhD, ARNP, CRRN, FAAN, FAANP Kathy Duncan, RN Expedition Coordinator
More informationREDUCING READMISSIONS
REDUCING READMISSIONS UnityPoint Health - St. Luke s Hospital Cedar Rapids, Iowa IHI National Forum December 2014 - Orlando, Florida ST. LUKE S HOSPITAL UNITYPOINT HEALTH SYSTEM Private hospital Cedar
More informationIHI S APPROACH TO REDUCING REHOSPITALIZATIONS IN THE STAAR INITIATIVE: OVERVIEW
Session M1 This presenter has nothing to disclose IHI S APPROACH TO REDUCING REHOSPITALIZATIONS IN THE STAAR INITIATIVE: OVERVIEW Pat Rutherford, RN, MS, Vice President, Institute for Healthcare Improvement,
More informationThe STAAR Initiative
The STAAR Initiative A quality effort at the heart of system redesign Amy E. Boutwell, MD, MPP The Center for Innovative Healthcare Strategies amy@innovativehealthcarestrategies.org Please note: Dr Boutwell
More informationFebruary 27, Mobilizing Skilled Nursing Facilities to Reduce Avoidable Rehospitalization: New Imperatives and New Models
1 February 27, 2014 Mobilizing Skilled Nursing Facilities to Reduce Avoidable Rehospitalization: New Imperatives and New Models 2 Having Audio Issues? If you experience any disruptions or other issues
More informationPartner with Health Services Advisory Group
Partner with Health Services Advisory Group Bonnie Hollopeter, LPN, CPHQ, CPEHR Health Services Advisory Group (HSAG) Quality Improvement Lead Rosalie McGinnis, MS, RN HSAG Quality Improvement Lead November
More informationTransitions in Care. Why They Are Important and How to Improve Them. U. Ohuabunwa MD
Transitions in Care Why They Are Important and How to Improve Them U. Ohuabunwa MD Learning Objectives Define transitions in care and the roles patients and providers play in safe transitions Describe
More informationPresenter Disclosure
Improving Transitions from the Hospital to Community Settings IHI National Forum Learning Lab Sunday, December 9, 2012 Session L20 Presenter Disclosure Leora Horwitz, MD Assistant Professor of medicine
More informationMinicourse Objectives
Session M1 This presenter has nothing to disclose SINAI-GRACE HOSPITAL Vanguard Health Systems/Detroit Medical Center Peggy Segura RN, MSN, FNP-BC Nurse Practitioner, Quality & Safety/Clinical Effectiveness
More informationTransitioning Care to Reduce Admissions and Readmissions. Sven T. Berg, MD, MPH Julie Mobayed RN, BSN, MPH
Transitioning Care to Reduce Admissions and Readmissions Sven T. Berg, MD, MPH Julie Mobayed RN, BSN, MPH Disclaimer: Potential for Error Type One Error Rejecting the null hypothesis when it is true
More informationImproving Transitions to Home & Community- Based Care Settings
This presenter has nothing to disclose. Improving Transitions to Home & Community- Based Care Settings Eric Coleman September 29, 2015 Session Objectives Participants will be able to: Describe the role
More informationIHI Expedition Expedition: Making Mental Health Care Safer in the Hospital Setting Session 6: Being Proactive and Avoiding Crises
February 24, 2015 IHI Expedition Expedition: Making Mental Health Care Safer in the Hospital Setting Session 6: Being Proactive and Avoiding Crises James F. O Dea, PhD, MBA Michael Claeys, MBA, LPC Kelly
More informationREDUCING READMISSIONS through TRANSITIONS IN CARE
REDUCING READMISSIONS through TRANSITIONS IN CARE Christina R. Whitehouse, PhD, CRNP, CDE Postdoctoral Research Fellow NewCourtland Center for Transitions and Health University of Pennsylvania School of
More informationSession Three Foundational Element: Engagement
Session Three Foundational Element: Engagement Kelly McCutcheon Adams, MSW, LICSW, IHI Director Barbara Balik, RN, EdD, IHI Faculty February 8, 2012 2:00 3:00pm EST David Kim David Kim, Institute for Healthcare
More informationIHI Expedition. Today s Host 9/17/2014. Preventing Pressure Ulcers
Tuesday, July 8, 2014 These presenters have nothing to disclose IHI Expedition Preventing Pressure Ulcers Kathy Duncan, RN Annette Bartley, RN Today s Host 2 Kayla DeVincentis, CHES, Project Manager, Institute
More informationAdmissions, Readmissions & Transitions Core Functions & Recommended Actions
How to use this resource An important single component of COMPASS for accomplishing the goals promised to CMS is the reduction of avoidable hospital admissions and readmissions as well as emergency room
More informationProject Title: Inter-professional Clinical Assessment Rounding & Evaluation (I-CARE) Rosiland Harris, DNP, RN, RNC, ACNS-BC, APRN
Project Title: Inter-professional Clinical Assessment Rounding & Evaluation (I-CARE) Rosiland Harris, DNP, RN, RNC, ACNS-BC, APRN Grady Health System Level I Trauma Center Burn Center Comprehensive Stroke
More informationUCSF Transitional Care Program. Maureen Carroll RN CHFN Transitional Care Manager Heart Failure Program Coordinator November 1, 2016
UCSF Transitional Care Program Maureen Carroll RN CHFN Transitional Care Manager Heart Failure Program Coordinator November 1, 2016 Session Objectives Describe elements necessary for building a cross continuum
More informationTransitions of Care: From Hospital to Home
Transitions of Care: From Hospital to Home Danielle Hansen, DO, MS (Med Ed) Associate Director, LECOM VP Acute Care Services & Quality/Performance Improvement, Millcreek Community Hospital Objectives Discuss
More informationPresenter Disclosure Information
The following program is co-provided by the American Heart Association and Health Care Excel, the Medicare Quality Improvement Organization for Kentucky. 3/1/2013 2010, American Heart Association 1 1 2
More informationTransitions of Care: The need for collaboration across entire care continuum
H O T T O P I C S I N H E A LT H C A R E, I S S U E # 2 Transitions of Care: The need for collaboration across entire care continuum Safe, quality Transitions Ef f e c t iv e Collaborative Successful The
More informationPharmacy s Role in Decreasing Hospital Readmissions
Pharmacy s Role in Decreasing Hospital Readmissions ACPE UAN 107-000-11-004-L04-P & 107-000-11-004-L04-T Activity Type: Knowledge-Based 0.15 CEU/1.5 Hr Program Objectives for Pharmacists: Upon completion
More informationThe BOOST California Collaborative
The BOOST California Collaborative California HealthCare Foundation Hospital Association of Southern California LA Care Health Plan The John A. Hartford Foundation Objectives for the Day Review the rationale
More informationThe Community Care Navigator Program At Lawrence Memorial Hospital
The Community Care Navigator Program At Lawrence Memorial Hospital Presented By: Linda Gall, MSN, RN, ACM Director of Care Coordination October 21, 2011 Learning Objectives: 1. Describe the vision and
More informationReducing Hospital Readmissions: Home Care as the Solution
Reducing Hospital Readmissions: Home Care as the Solution Kathy Duckett RN, BSN Sutter Center for Integrated Care ducketk@sutterhealth.org www.suttercenterforintegratedcare.org Learning Objectives 1 Review
More informationBaystate Medical Center
Baystate Medical Center STAAR Collaborative February 2 & 3 2011 680 bed tertiary care referral center ( ~1M) Flagship of Baystate Health 42 k admissions/year Annual surgical volume: 29,043 Western Campus
More informationH2H Mind Your Meds "Challenge. Webinar #3- Lessons Learned Wednesday, April 18, :00 pm 3:00 pm ET. Welcome
H2H Mind Your Meds "Challenge Webinar #3- Lessons Learned Wednesday, April 18, 2012 2:00 pm 3:00 pm ET 1 Welcome Take Home Messages Understand how to implement the Mind Your Meds strategies and tools in
More informationCoordinated Outreach Achieving Community Health (COACH) for Heart Failure Learning Objectives
Coordinated Outreach Achieving Community Health (COACH) for Heart Failure Session C917 October 9, 2015 Colleen Cameron, DNP, FNP-BC Rochelle Eggleton, MBA, BS, RN Susan Spink, BSN, RN-BC Linda Griffin,
More informationM7: Reducing Avoidable Rehospitalizations. Overview of the Problem and Promising Approaches
M7: Reducing Avoidable Rehospitalizations Overview of the Problem and Promising Approaches Eric A. Coleman, MD, MPH Director, Care Transitions Program This presenter has nothing to disclose. Session Objectives
More informationIntermediate Coronary Care Unit Rotation
1 Intermediate Coronary Care Unit Rotation Section of Cardiology Dartmouth-Hitchcock Medical Center (2008-2009) I. Overview of Rotation The cardiology-specific critical care experience is in the Intermediate
More informationScholarship Program St. Luke s Foundation Scholarship Recipients
2017 St. Luke s Foundation 2016 Scholarship Recipients St. Luke s Foundation s provides tuition assistance to St. Luke s employees pursuing a degree to expand or further their job skills. Scholarships
More informationTrends in Home Care: Everybody Wants to Be There. Barbara A McCann Chief Industry Officer
Trends in Home Care: Everybody Wants to Be There Barbara A McCann Chief Industry Officer Trend 1: The Medicare Home Health Benefit: Limiting Positive Innovation and Comfort It is an acute illness benefit
More informationPresenter Disclosure
Improving Transitions from the Hospital to Community Settings IHI National Forum Learning Lab Sunday, December 8, 2013 Presenter Disclosure MaryAnne Elma, MPH Quality Implementation and Innovations Director
More informationIHI Expedition Antibiotic Stewardship Session 1
March 20, 2014 These presenters have nothing to disclose IHI Expedition Antibiotic Stewardship Session 1 Diane Jacobsen, MPH Scott Flanders, MD Arjun Srinivasan, MD Expedition Coordinator 2 Kayla DeVincentis,
More informationCMS-0044-P; Proposed Rule: Medicare and Medicaid Programs; Electronic Health Record Incentive Program Stage 2
May 7, 2012 Submitted Electronically Ms. Marilyn Tavenner Acting Administrator Centers for Medicare and Medicaid Services Department of Health and Human Services Room 445-G, Hubert H. Humphrey Building
More informationPave Your Path: How to Improve-Will, Ideas and Execution
Pave Your Path This presenter has nothing to disclose Pave Your Path: How to Improve-Will, Ideas and Execution Cory Sevin, RN, MSN, NP Director, IHI Kate Bones, MSW Director, IHI February 19, 2013 Organization
More informationPatient and Family Caregiver Interview Tool
Patient and Family Caregiver Interview Tool Instructions: We recommend you select at least 5-10 patients who have been readmitted to your organization within the past 30 days to include in the group of
More informationChronic Care Management Services: Advantages for Your Practices
Chronic Care Management Services: Advantages for Your Practices Rachel S. Eichenbaum, RN, MSN Yvonne La-Garde, M.ED Susan Whittaker, CPC, CPMA This material was prepared by the New England Quality Innovation
More informationInstitutional Handbook of Operating Procedures Policy
Section: Clinical Policies Institutional Handbook of Operating Procedures Policy 09.01.13 Responsible Vice President: EVP and CEO Health System Subject: Admission, Discharge, and Transfer Responsible Entity:
More informationUsing Facets of Midas+ Hospital Case Management to Support Transitions of Care. Barbara Craig, Midas+ SaaS Advisor
Using Facets of Midas+ Hospital Case Management to Support Transitions of Care Barbara Craig, Midas+ SaaS Advisor What does Transitional Care Include? Transitional Care is the smooth conversion of a patient
More informationOrganization. Hospital to SNF Communication. Care Coordination Goals. Chasing the Perfect Handoff The Missing Link to Interoperability 7/18/2016
Organization Chasing the Perfect Handoff The Missing Link to Interoperability Annette Brown, BSN, RN Director, Clinical Informatics Eisenhower Medical Center abrown@emc.org Not for profit, academic, community
More informationImprovements in Care-Transitions: A Case Study of St. Luke s Hospital
[CASE STUDY] January 18, 2012 Improvements in Care-Transitions: A Case Study of St. Luke s Hospital Prepared for the Centers for Medicare and Medicaid Services 2012 The Brookings Institution Foreword The
More informationThe Stepping Stones Project Care Transitions and the Coaching Model
The Stepping Stones Project Care Transitions and the Coaching Model Selena Bolotin, MSW Care Transitions Project Manager Quality & Safety Initiatives Qualis Health Seattle, Washington About Qualis Health...
More informationThe presentation will begin shortly.
The presentation will begin shortly. The content provided herein is provided for informational purposes only. The views expressed by any individual presenter are solely their own, and not necessarily the
More informationThe Changing Landscape: A Confluence of National Attention. Eric A. Coleman, MD, MPH
Infusing True Person Centered Care into Improving the Quality of Transitional Care What Are the Primary Goals for Transitioning Patients from Hospitals? Eric A. Coleman, MD, MPH, AGSF, FACP Professor of
More informationWhat is Transition of Care?
Transitions of Care and Reducing Readmissions Jackie Vance, RN, CDONA, FACDONA Director of Clinical Affairs and Industry Relations, AMDA NTOCC is chaired and coordinated by CMSA in partnership with sanofi
More informationTransitional Care and Preventing Readmissions in San Francisco
Transitional Care and Preventing Readmissions in San Francisco 24th Annual Medical Surgical Conference April 10, 2014 South San Francisco Conference Center San Francisco Transitional Care Program Carrie
More informationSoutheast Michigan See You in 7 Hospital Collaborative: Session 2 Webinar. Tuesday, June 19 at 8 am
Southeast Michigan See You in 7 Hospital Collaborative: Session 2 Webinar Tuesday, June 19 at 8 am Agenda Administrative Buy-In & Getting Projects Off the Ground - Maureen Bowman, R.N., Vice President
More informationAdverse Drug Events and Readmissions: The Global Picture
Adverse Drug Events and Readmissions: The Global Picture Kyle E. Hultgren, PharmD Managing Director Center for Medication Safety Advancement Purdue University College of Pharmacy Indianapolis, IN 4 Learning
More informationNavigating the Hospital Readmission Reduction Program
Navigating the Hospital Readmission Reduction Program Since the Affordable Care Act passed in 2010, a hospital s 30-day readmission rate has become synonymous with quality of care. Beginning in 2012, the
More informationImproving Transitions Across the Continuum of Care
Improving Transitions Across the Continuum of Care Presented By: Cheri A. Lattimer, RN, BSN - Executive Director, NTOCC NTOCC is a 501(c)(4) nonprofit coalition. The Statistics Were Staggering In 2006
More information11/7/2016. Objectives. Patient-Centered Medical Home
Team-Based Care November 10, 2016 Objectives Overview of Patient-Centered Medical Home (PCMH) Recognition Overview of PCMH Team-Based Care Discuss examples of practice teams in Montana health centers Source:
More informationHow-to Guide: Improving Transitions from the Hospital to the Clinical Office Practice to Reduce Avoidable Rehospitalizations
How-to Guide: Improving Transitions from the Hospital to the Clinical Office Practice to Reduce Support for the How-to Guide was provided by a grant from The Commonwealth Fund. Copyright 2012 Institute
More informationSIMPLE SOLUTIONS. BIG IMPACT.
SIMPLE SOLUTIONS. BIG IMPACT. SIMPLE SOLUTIONS. BIG IMPACT. QUALITY IMPROVEMENT FOR INSTITUTIONS combines the American College of Cardiology s (ACC) proven quality improvement service solutions and its
More informationCare Transitions. Objectives. An Overview of Care Transitions Efforts in Arkansas
An Overview of Care Transitions Efforts in Arkansas June 6, 2013 Christi Quarles Smith, PharmD Manager, Quality Programs Care Transitions Project Lead Arkansas Foundation for Medical Care THIS MATERIAL
More informationCare Transitions: Don t Lose Your Patients
Care Transitions: Don t Lose Your Patients Sabrina Edgington, MSSW Program and Policy Specialist National Health Care for the Homeless Council March 14, 2013 CARE TRANSITIONS Definition The movement of
More informationImproving Primary Care Medication Patient Safety: System-level Medication Adherence Issues
Improving Primary Care Medication Patient Safety: System-level Medication Adherence Issues Marie Smith, PharmD Professor and Asst. Dean, Practice and Public Policy Partnerships Meg Mello Moniz, PharmD
More informationAt EmblemHealth, we believe in helping people stay healthy, get well and live better.
At EmblemHealth, we believe in helping people stay healthy, get well and live better. Welcome to the 2017 course on Special Needs Plan Model of Care. This year s course is focused on how we can successfully
More informationUNDERSTANDING THE CONTENT OUTLINE/CLASSIFICATION SYSTEM
BOARD OF PHARMACY SPECIALTIES CRITICAL CARE PHARMACY SPECIALIST CERTIFICATION CONTENT OUTLINE/CLASSIFICATION SYSTEM FINALIZED SEPTEMBER 2017/FOR USE ON FALL 2018 EXAMINATION AND FORWARD UNDERSTANDING THE
More informationJULY 2012 RE-IMAGINING CARE DELIVERY: PUSHING THE BOUNDARIES OF THE HOSPITALIST MODEL IN THE INPATIENT SETTING
JULY 2012 RE-IMAGINING CARE DELIVERY: PUSHING THE BOUNDARIES OF THE HOSPITALIST MODEL IN THE INPATIENT SETTING About The Chartis Group The Chartis Group is an advisory services firm that provides management
More informationProject Title: Inter professional Clinical Assessment Rounding & Evaluation (I CARE)
Project Title: Inter professional Clinical Assessment Rounding & Evaluation (I CARE) Rosiland Harris, DNP, RN, RNC, ACNS BC, APRN Project Director Pamela Gordon, DNP, RN Project Manager Grady Memorial
More informationNational League for Nursing February 5, 2016 Interprofessional Education and Collaborative Practice: The New Forty-Year-Old Field
National League for Nursing February 5, 2016 Interprofessional Education and Collaborative Practice: The New Forty-Year-Old Field Barbara F. Brandt, PhD, Director Associate Vice President for Education
More informationIHI Change Conference: Leading at the Edge Informational Call
September 19, 2017 1:00 PM 2:00 PM ET IHI Change Conference: Leading at the Edge Informational Call Fall 2017 WebEx Quick Reference 2 Please use chat to All Participants for discussion & questions Raise
More informationnicheprogram.org 2016 Annual NICHE Conference Care Across the Continuum 1
Phelps Memorial Hospital Center 5 South Bernadette Hogan, RN, Nurse Manager, Telemetry Mariel Consagra, RN, Anne Moss, RN Blessy Jacob, Pharm D, Clinical Pharmacy Coordinator Demographics 283 acute care
More informationIHI Expedition. Engaging Frontline Teams to Create a Culture of Safety. March 28 th, Annette Bartley, RN, MS, MPH Tracy Jacobs, BSN, RN
March 28 th, 2013 These presenters have nothing to disclose IHI Expedition Engaging Frontline Teams to Create a Culture of Safety Annette Bartley, RN, MS, MPH Tracy Jacobs, BSN, RN Today s Host 2 Lizzie
More informationRAISING THE BAR: IPRO s Medicare Quality Improvement Report for New York State ( )
RAISING THE BAR: IPRO s Medicare Quality Improvement Report for New York State (2011 2014) The Centers for Medicare & Medicaid Services (CMS) leads a national healthcare quality improvement program, which
More informationMeet DEAN & EDNA: The Application of HHQI Resources in the Reduction of Avoidable Hospitalizations
Meet DEAN & EDNA: The Application of HHQI Resources in the Reduction of Avoidable Hospitalizations Cindy Sun, MSN, RN Objectives At the conclusion of this session, the participant will be able to: Access
More informationCare Continuum or Unconnected Silos
Care Continuum or Unconnected Silos Julie Bynum, MD, MPH Dartmouth Medical School December 10, 2009 Goals for Today Review what we have heard & introduce what we have not heard Understand the components
More informationCMS Proposed Rule. The IMPACT Act. 3 Overhaul Discharge Planning Processes to Comply With New CoPs. Arlene Maxim VP of Program Development, QIRT
Overhaul Discharge Planning Processes to Comply With New CoPs Arlene Maxim VP of Program Development, QIRT 1 CMS Proposed Rule Included discharge planning specifics However, when the CoPs were finalized,
More informationSTRATEGIES AND SOLUTIONS FOR REDUCING INAPPROPRIATE READMISSIONS
WHITE PAPER STRATEGIES AND SOLUTIONS FOR REDUCING INAPPROPRIATE READMISSIONS This paper offers a two-pronged approach to lower readmission rates and avoid Federal penalties. Jasen W. Gundersen, M.D., M.B.A.,
More informationPharmacists Improve Care Through Team Collaboration
Pharmacists Improve Care Through Team Collaboration Trista Pfeiffenberger, PharmD, MS Director, Network Pharmacy Programs Community Care of North Carolina Disclosure and Conflict of Interest I am an employee
More information2.b.iv Care Transitions Intervention Model to Reduce 30-day Readmissions for Chronic Health Conditions
2.b.iv Care Transitions Intervention Model to Reduce 30-day Readmissions for Chronic Health Conditions Project Objective: To provide a 30-day supported transition period after a hospitalization to ensure
More informationImproving Transitions of Care
Improving Transitions of Care A Strategy to Defer Decline How the Foundation Got Started with Care Transitions First Quality Improvement Collaborative 2005-2006 Teams chose palliative care or transitions
More informationPatient Care Excellence Award Program
Patient Care Excellence Award Program 2017 Official Nomination Form UnityPoint Health - St. Luke's Foundation UnityPoint Health - St. Luke's Hospital UnityPoint Health - Continuing Care Hospital UnityPoint
More informationTransitions of Care. Objectives 1/6/2016. Roman Digilio, PharmD PGY1 Resident West Kendall Baptist Hospital. The author has nothing to disclose.
Transitions of Care Roman Digilio, PharmD PGY1 Resident West Kendall Baptist Hospital 1 The author has nothing to disclose. 2 Objectives Discuss current healthcare trends and the need for pharmacists in
More informationREADMISSION ROOT CAUSE ANALYSIS REPORT
USE RESTRICTED TO ABC Hospital READMISSION ROOT CAUSE ANALYSIS REPORT State: Community Name: YZ Cohort: Hospital: A ABC Hospital Reviewer: Jane Doe Abstraction Period: 1/1/2014 6/30/2014 Charts Abstracted:
More informationA Regional Payer/Provider Partnership to Reduce Readmissions The Bronx Collaborative Care Transitions Program: Outcomes and Lessons Learned
A Regional Payer/Provider Partnership to Reduce Readmissions The Bronx Collaborative Care Transitions Program: Outcomes and Lessons Learned Stephen Rosenthal, MBA President and COO, Montefiore Care Management
More information