Our ARC Journey Professional Home Care Associates Cheryl Haynes

Our ARC Journey…Professional Home Care Associates Cheryl Haynes RN BSN Nursing Supervisor

Brief History: l l l l Feb 2009 - Valley Care shared their educational material for CHF with agency March 2009 - Started post discharge collaboration Jan 2011 - First ARC meeting with Valley Care Feb 2011 - Joined CHF PI team at Valley Care March 2011 - Started weekly case conferences on CHF patients with home care staff. April 2011 - Developed “CHF Red Flag” form April 2013 - Developed D/C review tool

How We Connect to the Transitions Team at Valley Care: l l Weekly reports faxed to transition coach Phone calls as needed Ongoing support from Transition coaches with trouble shooting for complex/high risk cases Attend monthly PI meetings at hospital

What is the process during Handoffs?

The Process is simple: l l l T. C. from D/C planner about CHF referral & indicates patient is “CHF Protocol” Home care receives H&P, updated D/C medication list, & orders Intake coordinator communicates with Home RN that pt. is “CHF protocol” & gives copy of educational material to RN Patient opened to home care day after hospital D/C (day 1) Weekly reports faxed to Transitional coach until patient reaches day 30

What Processes are Used to optimize communication? l Transitional Coach can call directly to RN following case (especially if coach is having trouble contacting pt. by phone) l Developed communication tool to MD- “Patient visit report” – – l Support/reinforcement by MD to pt/family Patient/family hearing same information from medical team Developed “CHF Red Flag” form to improve MD response time for patients showing symptoms

Success: l CHF Red Flag form – l Improved MD response time CHF report form – Stream line reports from field RN’s

Challenges: l l l Weekly case conferences before using report form. Timely MD responses before “red flag” form End of life issues/high risk patients Social issues Pt/family “buy in” regarding teaching

Key take home messages: l l l Be patient…process doesn’t happen overnight! Customize your process that will be feasible to your particular agency/hospital needs Anticipate making changes to your process as you move forward…. things don’t always go as planned.

Outcomes: l Current CHF readmission rate is 19% l Now using D/C review tool to study reasons/trends in readmissions. l Plan- expanding program to other diseases (MI, Pneumonia)

Questions? ? l Contact information: – – – Cheryl Haynes RN BSN Professional Home Care Associates (925)243 -1385 or email chaynes@prohomecare. com