Hospital-Home Care Collaboration Solutions

Transcription

1 Cllabratin Catalyst Cmmunity Hspital-Hme Care Cllabratin Slutins DSRIP Prject 2.b.viii

2 DSRIP Overview Delivery System Refrm Incentive Payment (DSRIP) Prgram The State has asked hspitals, dctrs, and ther health care prviders t band tgether as Perfrming Prvider Systems (PPS) t wrk tward DSRIP s fremst gal f reducing avidable hspital use by 25% ver five years. 2

3 Prject Objective The bjective f DSRIP Prject 2.b.viii is t reduce re-admissins fr high-risk patients by implementing an INTERACT -like prgram in hme care settings. 3

4 Prject Descriptin Patients are nw being discharged t a less restrictive alternative, primarily their wn hme. Risks f ptential nn-cmpliance with: Discharge regimens; Missed prvider appintments; Less frequent bservatin by medical staff. 4

5 Transitin Care Management This prject will put services in place t address these risks by matching services with transitin care management (TCM). Patients having cmplex medical and/r psychscial prblems; Require at least mderate medical decisin-making; Transitins in care frm inpatient hspital t patient s cmmunity (hme, assisted living); Services expected t > 30 days. 5

6 Milestnes Milestne 1: Assemble Rapid Respnse Teams (hspital/hme care) t facilitate patient discharge t hme and assure needed hme care services are in place. Milestne 2: Ensure hme care staff have knwledge and skills t identify patient risks fr readmissins, as well as t supprt evidence-based medicine and chrnic care management. Milestne 3: Develp care pathways/clinical tls fr mnitring critically ill patients, with the gal f aviding hspital transfer. 6

7 Milestnes Milestne 4: Educate staff n care pathways and INTERACT -like principles. Milestne 5: Develp Advance Care Planning tls t assist residents and families in expressing and dcumenting wishes fr end f life care. Milestne 6: Create a caching prgram t facilitate and supprt implementatin. 7

8 Milestnes Milestne 7: Educate patient and family/caretakers t facilitate participatin in planning f care. Milestne 8: Integrate primary care, behaviral health, pharmacy, and ther services t enhance crdinatin f care and medicatin management. Milestne 9: Utilize telehealth/telemedicine t enhance hspitalhme care cllabratins. 8

9 Milestnes Milestne 10: Utilize interperable EHR t enhance cmmunicatin, avid medicatin errrs and/r duplicative services. Milestne 11: Measure utcmes (including quality assessment/rt cause analysis f transfer) t identify additinal interventins. Milestne 12: Use EHRs and ther technical platfrms t track patients engaged in this prject. 9

10 Overview: INTERACT The INTERACT Quality Imprvement Prgram is designed t imprve the early identificatin, evaluatin, management, dcumentatin, and cmmunicatin f acute changes in cnditin f patients in HHA s. These strategies and tls can reduce the frequency f ptentially preventable transfers t the hspital and related cmplicatins and health care csts. 10

11 Quality Imprvement Tls Acute Care Transfer Lg tl fr recrding all acute care transfers during a mnth. QI Tl fr Review f Acute Care Transfer designed t help yur team analyze hspital transfers and identify pprtunities t reduce transfers that might be preventable. QI Summary summarize individual rt cause analyses f hspital transfers. 11

12 Cmmunicatin Tls Seems different than usual. Talks r cmmunicates less. Overall needs mre help. Stp and Watch Early Warning Tl fr Hme Health Aides Pain new r wrsening; mans r grimaces (fr patients with severe dementia), participates less in activities. Ate less. N bwel mvement in 3 days, r diarrhea. Drank less. Weight change. Agitated r nervus mre than usual. Tired, weak, cnfused, r drwsy. Change in skin clr r cnditin. Help with walking, transferring, tileting mre than usual. 12

13 Cmmunicatin Tls SBAR Cmmunicatin Frm Situatin: Change in cnditin, symptms, r signs. Backgrund: Patient descriptin, Medicatin alerts, Vital signs, Patient Evaluatin. Assessment (RN) r Appearance (LPN): What d yu think is ging n with the patient? 13

14 Cmmunicatin Tls Hme Health t Hspital Transfer Frm: used t relay infrmatin t the nurse respnsible fr the patient. Hme Health t Hspital Transfer Data: t prvide guidance n key data elements critical fr effective care at the time f transitin t hspital. Acute Care Transfer Dcument Checklist: ensures the crrect dcument is sent with the patient. 14

15 Cmmunicatin Tls Hspital t Pst-Acute Care Data List: t prvide guidance n key data elements critical fr effective care at the time f transitin Medicatin Recnciliatin Wrksheet fr Pst-Hspital Care: used t help dcument medicatin. 15

16 Acute Change in Cnditin Tl(s) Decisin Supprt Tls Care Paths Acute Mental Status Changes Changes in Behavir: Evaluatin f causes f new/wrsening symptms Dehydratin (ptential fr) Fever GI Symptms SOB Symptms f CHF Symptms f Lwer Respiratry Infectin Symptms f UTI 16

17 Advance Care Planning Tls Advance Care Planning Overview Identifying Patients Cmfrt Care/Palliative Care Interventins Cmfrt Order Set (MD rders fr palliative care) Patient/Caregiver Educatin 17

18 DSRIP Prject Manager: Betsey Twne Prject Champin: Elizabeth Zicari