Breakout A: Ensuring Post-Hospital Care Follow-up Metro. West Medical Center Metro. West Home Care & Hospice Linda Campbell, RN VP, Quality & Patient Safety Natalie Kenney, RN Home Care, Heart Failure Nurse Specialist, Transition Care Nurse
Community Partnerships • Community Partners in the Metro. West area: – Local LTACs and SNFs – • Bethany Health Care Center • Carlyle House • Kathleen Daniels Healthcare • Kindred Healthcare • Mary. Ann Morse Nursing & Rehab Center • Oak Knoll Nursing Center • River Bend Nursing Center • St. Patrick’s Manor • Timothy Daniels House • Wingate Healthcare – Evercare – Bay. Path Elder Services – Community Physician Practices
Telephonic Care – Post-discharge • 09/2010 - Post-discharge telephonic care program instituted for HF pts. • 01/2011 - Project expanded to include AMI & Pne • Identification methodology, via electronic daily file: – HF – disch from ED to Inpt. with certain Dx codes, “lasix given”, BNP > _ – AMI – Disch from ED to Inpt. with certain Dx codes, Troponin > _ – Pneumonia – Disch from ED to Inpt. with certain Dx codes, CM recommended Abx given
Community Partnerships • • • Call program Piloted with one local SNF Expanded Community Partnership concept to include an Educational Collaborative with local LTACs & SNFs Partners identified through Case Management major referral patterns 3 face-to-face meetings since early 2011 3 defined workgroups – – – Education Clinical Care Communication
Education Program • Standardized Education Program developed • Inpt. teaching tools adapted for LTAC & SNF • Education provided to 7 facilities, 152 total participants – 110 licensed staff, 42 CNAs • Focus on Early Recognition of symptoms and Treat in Place • Teaching tools included INTERACT & SBAR tool
Clinical Care • Need for coordinated care into the Community • Workgroup to develop coordinated Plans of Care / Clinical Pathways / Care Protocols • First for Heart Failure, then other Dxs • Target date for completion – 11/1/2011
Communication • Workgroup to include hospital IT rep, Case Management, Community reps • Address electronic communication – – Use of Cura. Span – auto packet of info to go from hospital to facilities upon discharge • Explore other communication options
Process/Outcome Data 30 -Day All-Cause Readmissions for HF Patients
Lessons Learned • Teaching Program – Originally presented to mixed audience of licensed staff and CNAs – Refined to program for licensed staff given by Home Care RN; CNA program presented to facility Staff Development as Train-the Trainer for CNAs • It takes a Village
Next Steps • Continue to Partner with Facilities • Develop Community Physician Partnership • Engage everyone!!!
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