Study: Outcomes and Evaluation Act: Conclusions and Planning Transitions of Care: Crossing Chasms Between Inpatient and Outpatient Care Through Care Management Rebecca Joostens RN, BSN Ferris State University Plan: Study: Outcomes and Evaluation Act: Conclusions and Planning Collaboration of departments resulted in a new, lean communication workflow, a new nurse-to-nurse report script was written and a staff education tool was created that addressed the previously identified barriers. A feedback loop was incorporated into the workflow for timely response to new concerns. Purpose: Reduce hospital readmissions of patients identified as high risk utilizing communication workflows between inpatient and outpatient care management departments at the time of patient discharge from acute care. Objectives: overcoming communication and inter-departmental cultural barriers between the RN CM departments to increase number of impactful warm handover conversations which would then lead to decreased readmission rates in patients identified as high risk for readmission. Literature Review Multidisciplinary approach Utilization of nurses Tight communication with PCP clinic Risk stratification tool such as the LACE index Adding a social determinant component to high risk patient identification These concepts were used in this project to support the warm handover process changes and staff education. Barriers: Many education and cultural barriers prevented this work from being as successful as possible. Utilizing transformational leadership and change theories, staff were empowered to Be creative in identifying solutions and Creating new workflows. The prediction is that staff will need ongoing support and education on these topics. A survey will be collected one month after go-live of the project to determine if RN CMs’ confidence remains high in their belief in the importance of this work and their ability to complete the workflow Next Steps: The workgroup will continue meeting on a monthly basis to continue studying outcomes and areas for improvement. Items Identified thus far: Improve on staff belief in the benefit of the script Improve staff confidence in use of social determinants alone, when no LACE score available. The need for social work involvement Long Term success of the project will be determined by reporting of number of warm handovers in comparison with readmission rates. Results Surveys were used to assess the nurse care manager’s knowledge of the process, understanding of patient risk and beliefs in their ability to improve patient care during the transitions period Results suggest that RN CMs are knowledgeable/ confident in: What is expected of them in the warm handover process The significance of the warm handover Their ability to improve patient transitions What information is helpful in a warm handover. Results suggest RN CMS are less confident in: the benefit of the warm handover script the benefit of beginning the workflow based on social determinants only (LACE not available) Challenges Originally, the metric was the frequency at which nurse care managers utilized a new workflow and successfully completed the warm handover. However, early in the project, the deep-rooted cultural barriers caused poor staff engagement altered the focus and timeline. The project focus changed from streamlining the workflow alone to a focus on relationship building between departments, change management and creating a culture of change. Therefore, the metric was changed to measure the care managers’ confidence in the value of the work, their understanding of the workflow and their belief in their ability to impact patient care through this collaboration. Description Over coming barriers: Lippit’s Change Theory Transformational Leadership Theory Empower Care Managers Process Improvement: Inpatient and ambulatory RN CM departments together went through process improvement to create a communication workflow using Lean principles Deliverables: Innovative solutions for the communication workflow Education of staff Evidence Based Practice Validation of the LACE RN CM Roles Warm handover scripting Process for identification of high risk patients Inclusion of social determinants of health Acknowledgements The author has no financial disclosures. A special thanks to Kim Doherty, RN, BSN, MSN and Tal Harris MSN, RN, ACM for their support and assistance throughout this project It is our hypothesis that improved attitudes and beliefs measured in the surgery will result in more frequent use of the warm handover process and therefore will be tracking the frequency .