Prioritizing the SASH World Amy Perez, SASH Statewide Support Coordinator

Kristi Poehlmann, RN, SASH HSE & Nurse Consultant

Melissa Southwick, , SASH Statewide Support Coordinator

1. Objective

2. Roles and Responsibilities

3. What is SASH?

4. Staff tasks by Intervention Area

5. Flow chart for prioritization

6. WN/SC Meeting Guide

7. Principles of Prioritization

8. The Big Picture

9. Q&A

The tools you use to effectively manage your panels so your panels don't manage you.

Agenda

Objectives

• At the end of this session you will be able to –

1. Describe shared priorities between the SC & WN

2. Describe the purpose of the weekly SC & WN meeting and how to have this type of meeting

3. Describe priorities within your SASH Panel

4. Describe the tools that are available to you to help you prioritize your SASH Day and Panel Activities

Roles/Responsibilities

• Put your Post-It notes on the tasks that you are responsible for.

– **DON’T WRITE ON YOUR POST-IT NOTE – WE WANT TO LOOK AT COLORS. THANKS!

What is SASH (in one sentence)?

SASH harnesses the strengths of social service agencies, health providers, non-profit housing organizations and the SASH

participant to work together to support Vermonters to live safely and healthfully at home.

Our SHARED GOAL as the SC/WN Team

The SASH Model Focuses on Three Components of Care Management

6

• Coordinates with discharge staff, family and neighbors

• Personal visit to review discharge instructions

• Helps ensure a safe home transition

Care Coordination

• Develops healthy living plan

• Coaches SASH Participants

• Provides reminders and in person check ins

• Organizes presentations and evidence based programs

Self Management

• Conducts wellness assessment

• Convenes SASH team

• Understands participants needs and preferences

• Coordinates individual/community healthy living plans

Transitional Care

How does SASH deliver those 3 Components?

Person-centered

SASH Staff embedded in

housing

Formal Partnerships

Information Sharing

Prevention and Wellness through Data-driven Healthy Living Planning

SASH Staff Tasks by Intervention Area SASH Coordinator Wellness Nurse

Transitions Support

and Coordination

Communicates with discharge staff at hospitals

and skilled-nursing facilities

Attends discharge planning meetings

Communicates with family members/support

persons

Visits SASH participant to review discharge

instructions

Coordinates with SASH team to help facilitate a

safe transition home

Communicates with SASH team and family members regarding

transitions home

Visits SASH participant at home as soon after discharge as

possible

Works with SASH team to coordinate regular check ins and/or

medication reminders as needed

Updates Participant record with new medications or

treatments as appropriate

Self-Management Develops Community Healthy Living Plan (CHLP)

with SASH team

Provides individual and group encouragement to

SASH participants in meeting self-management

goals

Provides regular reminders and/or in-person

checks with SASH participants as needed

Organizes educational presentations and evidence

based programs

Provides individual home visits to high risk SASH participants

Assists SASH participants in setting up medication

management systems

Provides individual and group preventative interventions such

as blood pressure checks and weight monitoring

Provides information and education on self-management

strategies

Coordinated Care Coordinates with Nurse to schedule SASH

assessment for SASH participants

Convenes SASH Team meetings

Conducts individual person-centered interviews

Develops individual Healthy Living Plans (HLPs)

Supports SASH participants in meeting their HLP

goals

Conducts SASH assessments

Participates in SASH team meetings

Supports participants to meet their HLP goals

Identifies level of risk among SASH participants

Introduction

• Setting Priorities - essential and critical thinking skill

• Priority setting is perhaps the most critical skill in good time management, because all actions we take have some type of relative importance

• Management of a SASH Participant load depends heavily on setting priorities

Time Management

• Three Basic Steps in Time Management

– Allow time for planning and establish priorities

– Complete the highest priority task whenever possible and finish one task before beginning another

– Reprioritize based on the remaining tasks and on new information that may have been received

SASH Coordinator Day HOW TO PRIORITIZE THE SASH COORDINATOR’S DAY

Priority #1 – ALL SCHEDULED VISITS

Priority # 2- Scheduled SC Programming

Priority #3 – SASH Participants having a

problem/ongoing issue. Prioritize the following according to severity of

discussion between WN/SC:

Weekly SC/WN Collaborative meeting NEW SASH Assessments SASH Re-Assessments Person Centered Interview visits HLP sessions

These scheduled offerings are documented on the SASH Flash and/or monthly Calendar.

Cancelling last minutes decreases the future success of other SC programming.

Participants who have recently had transitions: from hospital/rehabilitation/skilled nursing home/Emergency Room (SCs have 48 hours to attempt contact once the participant returns home.)

Participants who have had a recent fall Participants who have had a major health change or new

diagnosis, therefore may need health education, referrals and/or support

Participant to whom you provide regular reminders and/or in-person check-ins

Participant experiencing life changes, recent loss, change in health status, who are having difficulty coping effectively (mental health issues)

Participants whom you are providing support with HLPs

Consider establishing two types of office hours Participant office hours where you can

redirect “frequent fliers” who come to your office to discuss the same issue daily.

SC office hours where you have planned “door closed” time to work on: o Document your encounter

notes (if it’s not documented it didn’t happen)

o Developing your Community Healthy Living Plan

o Organizing and communicating the agenda for your SASH team meeting

o Developing your SASH FLASHo Recruiting and supporting

volunteerso Time to provide caregiver/

family support as neededo Work on learning evidence

based programs you will offer to your participants.

Plan to be flexible: This may sound like an oxymoron but a

schedule that is too tight or too rigid will make it very difficult to be flexible. Remember that you are are working with people, and people are unpredictable. If you leave some “wiggle room” in your schedule each day you will more likely be able to attend that unforeseen discharge planning meeting, or help out when the ambulance arrives. If nothing arising during this flexible time in your schedule see about SC office time for ways to fill it.

Wellness Nurse Day

Priority #1 – ALL SCHEDULED VISITS

Priority # 2- SCHEDULED – A. Blood Pressure Clinic

B. Wellness Programming

Priority #3 – SASH Participants having a

problem/ongoing issue. Prioritize the following according to severity of

discussion between WN/SC:

HOW TO PRIORITIZE THE SASH WELLNESS NURSE DAY(S)

Weekly SC/WN Collaborative meeting NEW SASH Assessments SASH Re-Assessments WN 1:1 visits previously scheduled as

follow-up HLP sessions

These scheduled offerings are documented on the SASH Flash and/or monthly Calendar.

Cancelling last minutes decreases the future success of other WN Programming (clinical or

wellness presentation).

Participants requesting to see the Wellness Nurse –

please note the clinical or care coordination rationale for the nursing visit.

Participants who have recently had transitions: from

hospital/rehabilitation/skilled nursing home/Emergency Room

Participants who have had a recent fall

Participants who have had a major health change or new

diagnosis, therefore may need health education and/or referrals

Participants who have recently seen their primary care

provider or a specialist and would like follow-up with the Wellness Nurse

Participant with chronic conditions who requires

Wellness Nurse evaluation – i.e. vital signs, lung sounds, weight evaluation, medication management

Participant experiencing life changes, recent loss, change

in health status, who are having difficulty coping effectively (mental health issues)

**PLEASE NOTE – Wellness Nurses cannot see residents

that have not signed up with SASH. (this is an opportunity)

Priority #3

Is this a medical emergency?

Is this an Urgent Care need?

For Priority #3 – Always consider the following questions -

Call 911

Refer participant to

call PCP or go to Urgent Care

Obtain discharge paperwork and scenario

in order to brief WN. Is this a transition?

Is this a fall?

Obtain description of fall and how it transpired,

level of medical attention sought.

Is this a post – PCP or specialist meeting request?

Obtain the AFTER Visit Summary

Is this a Chronic Condition follow-up?

Discuss any Wellness checks or interactions with participants since

last visit

Is this a major health change/life change/recent loss/change

in health status?

Obtain Chief complaint for discussion with WN

Enter Green colored bubbles into JotForm

Review SC/WN Guide (hand-out)

Additional Principles of Prioritization

• Know the needs and priorities of your SASH Participants and Panel – This is rationale for the weekly SC/WN meeting

– Nurses will be able to identify participants needing to be seen first.

– After the WN assessment is completed – the WN and SC can discuss participant needs in terms of priority (i.e. needing to see the PCP today vs working on transportation, needing prescriptions vs attending the walking program)

Additional Principles of Prioritization, continued

• Consider all factors –

– What things can be delegated to others

– How much time is involved in some visit types (some visits take more time)

• Always remain flexible

– EVERYDAY, priorities need to be re-evaluated, reorganized depending on SASH panel changes

– i.e. hospital admissions, discharges home, falls, etc that impact your day to day operating schedule

Additional Principles of Prioritization, continued

• Use of Creativity –

– Emphasize patient’s abilities and strengths so that they may learn to assume MORE self-management of their conditions

– Encourage family participation (when possible) in care

Priority Setting Traps

• “Whatever hits first”

• “Path of least resistance”

• “Squeaky wheel”

• “Default”

• “Inspiration”

Simple Suggestions

• Procrastination –– 3 most common reasons are: – Not wanting to begin

– Not knowing where to begin

– Not knowing where to begin, even if you wanted to do, which you don't.

• Poor planning

• Failure to establish goals and objectives

• Inability to delegate

• Inability to say no

• Management by crisis

• Haste

• Indecisiveness

Time Wasters

• Group Programming

• Document as soon as possible after an activity is completed.

• Schedule tasks when the time is right

THE BIG PICTURE – WHAT’S THE RESULT?

What data looks like NOW Chronic Conditions

Data Collection -> Community Healthy Living Plan -> Monthly Offering & Individualized Healthy Living Plan

KEY Take-Aways

• Communication

• Organization

• Collaboration

• Delegation

• Follow-up

Questions?