3/31/2016 1 IHI Expedition Improving Care Transitions To Reduce Readmissions Session 5: Executing on an Ideal Outcome in the Transition: Right time, Right Place, Right level of care at the Right Cost March 31, 2016 These presenters have nothing to disclose Peg Bradke, RN, MA Jill Duncan, RN, MS, MPH Today’s Host 2 Colby Champagne, Project Assistant, Institute for Healthcare Improvement (IHI), is a co-op student from Northeastern University. She is a health science major with a minor in business administration and hopes to pursue a career in healthcare management. She is working on the Passport, Expeditions, and Leadership Alliance teams.
Transcript
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IHI ExpeditionImproving Care Transitions To Reduce Readmissions
Session 5: Executing on an Ideal Outcome in the Transition: Right time, Right Place, Right level of care at the Right Cost
Determinants of preventable readmissions in United States: a systematic review. Implementation Science 2010, 5:88
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Establish & Implement a Person
Centered Transition Plan to Meet the
Identified Post Acute Needs
Session 2
– Comprehensive Plan of Care
– Telephone follow up and triage
– Community Care Workers
– Assessing transition encounters across all sites of
care
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“….effectively communicate the
plan of care (based on the
assessed needs and capabilities)
to the patient/caregiver and
community-based providers of
care?”
How Might We….
Rutherford P, Nielsen GA, Taylor J, Bradke P, Coleman E. How-to Guide: Improving Transitions from the Hospital to Community Settings to Reduce Avoidable Rehospitalizations. Cambridge, MA: Institute for Healthcare Improvement;
June 2013. Available at www.IHI.org.
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Simply
What do we know about the patient/caregiver
that will help the next level provide the needed
care in the transitions?
How will we communicate that?
Sender Role vs Receiver Role
Develop one comprehensive assessment and
plan for the patients post-acute care needs that
integrates input from all members of the care
team
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Risk32
Is the answer in the
Patient’s
Story?
What did the
Comprehensive
Assessment tell us?
What are the Patient
and Caregiver telling
us?
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Include the Patient’s Perspective
Ask patient/caregiver:
What matter most to you during this transition?
What are your concerns or worries about going
home or to the next care setting?”
Who do you want involved in your transition
(your Support person)
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Rutherford P, Nielsen GA, Taylor J, Bradke P, Coleman E. How-to Guide: Improving Transitions from the Hospital to Community Settings to Reduce Avoidable Rehospitalizations. Cambridge, MA: Institute for Healthcare Improvement; June 2013. Available at www.IHI.org.
Customized Plan of Care
Develop one comprehensive assessment and plan of
patients post-acute 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 the assessment and plan
Consider:
– Patients Preferences
– Patient Capabilities
– Activation Level
Develop Bidirectional dialogue and collaboration
between sender and receivers
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How much coordination do you have?
How many services are wrapped around the patient/
caregiver?
– Are all the services communicating? Do they all understand the
Plan of Care?
– If there are multiple services involved is a “lead person” identified
and communicated to the patient/caregiver and the care team?
How many phone calls is that patient/caregiver receiving
after they get home?
– What are each of the calls purposes?
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Transitional Care Models
Session 3:
– Coleman Model
– Naylor Model
– Advanced Care Planning
– The Conversation Project
– Gunderson Respecting Choices
– Transition to Skilled nursing facilities
– Community Agency on Aging (AAA)
– Assignment: Become more aware of Community
Programs/Agency that could be working with you
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Patient and Family Engagement
Cross-Continuum Team Collaboration
Health Information Exchange and Shared Care Plans
Transition from Hospital to Home or other Care Setting
Transition to Community Care Settings and Better Models of Care
Supplemental Care for High-Risk Patients
The Transitional Care Model (TCM)
IHI’s Framework:
Improving Care Transitions
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A Valued Partner in the Community: Your
Local Area Agency on Aging
Available in nearly every community in the US
AAAs work directly with the older adult’s family to
improve planning; providing additional services including
