10/12/2011. Hospital Admissions. Length of stay. Patient and caregiver knowledge Patient empowerment

Transcription

1 How the Transition Coach Model is employed at United Memorial Medical Center Amy Snyder RN Since our program started at United Memorial Medical Center Home Visits Home Visits Home Visit thus far Our Goals of the Program Minimize Hospital Admissions Acuity of patient at the time of admission Length of stay Increase Patient and caregiver knowledge Patient empowerment 1

2 Process begins with Identifying potential patients for program Admissions register Referrals Case Manager MD Nursing Home discharging patients from rehab Disqualifiers Discharge to Nursing Home Discharge to Hospice Transfer to a higher level of care Co morbidities case by case evaluation Process begins with Identifying potential patients for program I meet with patients during their inpatient stay. I will call the patient or caregiver at home after discharge. if the discharge plan is potentially to a rehab situation if the patient is admitted and discharged prior to my meeting with them. Process begins with Identifying potential patients for program I present this to the patient and or caregiver as a care package or tools to help them manage the symptoms of Congestive Heart Failure. I tell them this is a free service that the hospital is providing to help keep them healthy. 2

3 During the Home Visit the goal is to cover the 4 Pillars D Daily Weight Monitor Sodium intake Monitor Daily symptoms Tk Take Mdi Medications i as directed dand dkeep up to date medication list. Encourage patient and caregiver to own their medical formation and be prepared to show updates and changes to other providers that may be involved in their care. Determine if a follow up appointment has been made since Hospitalization Care Package The Care Package or Tools is given to patients at the time of the Home Visit. 3

4 Items included in the Care Package A digital scales Calendar with cartoon captions Red Flags List A Li Living i with ihh Heart Failure C Calendar Companion Pill Box Notebook with attached pen Blank Medication List Leave Patients and or caregivers with a business card. Post Home Visit Letter to MD telling him/her that his/her patient has received these supplies. 3 follow up phone calls 1 month 3 months 6 months Phone call to MD and or caregiver if the home visit produced a concern for safety. Less is more in relation to educational materials The home visit needs to be tailored to the needs and education level of the patient. 4

5 Some patients are enlightened about sodium values in their food. They are often shocked on how quickly it adds up. One hot dog with condiments Hot dog itself mg Hot dog roll 200mg Ketchup 1 tbsp 160mg Mustard 1 tsp 60mg Relish 1 tbsp 100mg 1 hot dog totals 920 to 1120 mg sodium Some visits are spent with the emphasis on reconciling medications. One visit exposed several expired medications in a bag mixed with current medications. Another visit 30 medication bottles all over his kitchen table and freezer filled with hot dogs. Two other visits found scripts for Digoxin and Lasix that never made it to the patients home 5

6 Other visits especially those of compromised intellectual ability reinforcing the importance of daily weights when to call the doctor becomes the focus We have reached out to local Nursing Homes. I am actively taking referrals for discharged patients from rehab with the diagnosis of Congestive Heart Failure. If a patient who received a home visit is readmitted I try to stop in and see the patient in the hospital. 6

7 Life still needs to go on despite a CHF diagnosis. We have learned that not all patients are coachable and the program is best employed earlier than later in the disease process. Connections to further improve Patient Transitions Referrals are now being made to Disease Management Programs of the patient s Insurance Plan MVP Independent Health Community Blue/Blue Cross of WNY (Buffalo) Excellus/Blue Choice of Rochester Connections to further improve Patient Transitions Working with Genesee County Office of Aging Service Directory for Seniors, persons with disabilities i and their caregivers. Falls Prevention Program Referrals. Living Healthy Workshops. Interest to expand Transition Coaching to other chronic conditions such as COPD and DM 7