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