NICU Transfer to Primary Care Providing a Warm Hand-over from Hospital to Medical

Group

Shauri Kagie MSN, RN and Team

NICU Transitions Team Lead- Teresa Garrett, Integrated Care Management AVP

Central Office Kristy Nelson-Clinical Programs Manager Teri Kiehn-Women and Newborn Clinical Programs Manager Robyn Toth-Compliance Anne Armstrong-Counsel Sr. Division Director Matthew Murray-Data Manager Medical Group Catherine Hamilton, Case Management Leadership Shauri Kagie, Memorial Clinic Tammie Brandon, Northern Utah Pediatrics Hospitals Primary Children’s Hospital-Connie MacPherson, Evy Smyth McKay Hospital-Jean Millar, Mary Anne Leete Intermountain Medical Center- Kim Rawlins, Allyson Browning, Jenn Anker Select Health Chris Chytraus, Debby Moore Cerner Abby Zimbleman, Melanie Bradley

Objectives

1. Describe what the NICU Transition Project is. 2. Recognized and receive communication from hospital NICU Care Manager. 2. Utilize the NICU transition process. 4. Formulate ideas to improve transitions of care.

Problem

Medical Group Pediatric Care Managers in PCP offices identified communication was poor from Intermountain facilities when discharging new NICU graduates. They received little or no information regarding the patient. Finding specific information in records very time consuming, which made transition into the community difficult Objective: To improve care manager to care manager hand-over of the NICU high risk patients to community

Problems Identified

• PCP identification left until last minute if at all

• Patients not listed on hospital inpatient lists

• Lack of correct name on discharge

• Lack of communication with PCP

Tools Developed

• Process Flow • NICU Transition Communication Form • Tracking spreadsheet-Share Point

Process Flow

Main Points 1. Identify PCP within 1-2 weeks of stay 2. Communicate with IMG Care Manager as soon as

PCP identified. 3. Identify correct name for discharge 4. Notify SH Care Manager (for SH patients not being

seen in an IMG clinic) 5. 1:1 warm handover using NICU Transition form to

communicate with IMG care manager upon discharge

NICU to Community-Communication Tool

iCentra NICU Transition Document

iCentra NICU Transition Document-Cont.

Tracking

1.Originally started with Primary Children’s Hospital tracking discharges on excel spreadsheet. 2. New and improved system for tracking discharges in SharePoint.

NICU Transition Patients

Outcome Measures Measures for NICU Transition Beta Project

Did care manager to care manager hand-off occur? Did patient show for PCP apt? Was there any key information missing in the handoff that was later identified at the PCP appointment? If so what was it?

Outcomes: Care manager & physician satisfaction with process flow and improved communication Decrease in ED Visit within 30 days of discharge as compared to peers. Attendance to first visit in the pediatric practice within 7 days (or as indicated)

Data Elements Percentage of patients going to IMG Percentage of patients going to Family vs Pediatric practice

Scope of Project

• March/April 2015: Started with discharges from PCH to Memorial Clinic: lack of volume

• May 2015:Expanded quickly to include ALL IMG Clinics that receive NICU graduates from PCH

• July 2015: Expanded to McKay Dee and IMED as referring facilities

Problems Encountered

Identifying IMG patients Partial solution: SH report run daily for all SH NICU

patients Time Constraints New care manager at Primary Children’s with

average daily census of 40 high risk patients Phone call time consuming/lacked efficiency Hand-off form time consuming Insurance Medicaid HMO not identified in hospital

Results to date

PCH: 16 patients to IMG since April 2015 Contact with IMG CM: 15/16 Form used: 12/16 Patients referred to SH: 2/16 (since June) McKay Dee: 15 patients IMED: 36 patients

Receiving Clinics from IMED

Hillcrest Pediatrics-7 Sandy Pediatric-6 Southridge Pediatrics-5 Memorial Pediatrics-5 Kearns-2 Holliday-2 Bountiful-2 Bryner-1 Budge-1 Mountain View-1 North Valley Pediatrics-1

Continued Problems

• Time for NICU Care Manager continues to be a problem

• Many SH members do not choose Intermountain Medical Group Practices

• Currently no efficient way to identify patients going to IMG practice (SH report helps)

Accomplishments

• PCP identified early • Correct name identified early • Warm hand-over accomplished • Better communication and information to

PCP

Success

Melissa Higley, RN, Care Manager IMG Sandy Clinic “The hand offs I've had from the NICU have made the transition so smooth... It allows me to help the doctor know the needs of the child so they are also well prepared. There is no surprise when they show up at the clinic. ” “I had a NICU discharge as one of my first patients. There was no hand off. The NICU discharge note was convoluted. It was a young mom with a complicated kid. I spent hours trying to sort through what needed to be done, what had been done, etc. The 2 (and almost a third) I've had since that time have been far less time consuming and confusing. And it is not because the kiddos were any less complicated--in fact, they were more complicated. I very much appreciated the communication! ”

Questions?