FORGING PARTNERSHIPS IN THE CONTINUUM OF CARE

Slides:

Advertisements

Similar presentations

Care Coordinator Roles and Responsibilities

Advertisements

Special Educational Needs and Disability Pathfinder and Individual Budgets The approach in Gateshead February 2012.

Commonwealth Respite and Carelink Centre Presentation Who we are and what we do.

The Evolving Role of Nursing in ACOs and Medical Homes Carol A. Conroy DNPc RN CNOR Chief Nursing Officer/VP Operations VONL SUMMIT: April 19, 2013.

Community Care Access Centres Your Connection to Community Health Services and Long Term Care October 30, 2006 Val Armstrong, CCAC Simcoe County.

GEM, rehab and Transition care. Is time the real healer Dr Craig Whitehead.

Jennifer Hwang, MD, MHS Pediatric Advanced Care Team The Children’s Hospital of Philadelphia.

Coordinating Care Sierra Dulaney Lisa Fassett Morgan Little McKenzie McManus Summer Powell Jackie Richardson.

Essential Interventions for Improving Transitions of Care Presented By:Cheri Lattimer, RN, BSN - Executive Director, NTOCC & CMSA NTOCC is a 501(c)(4)

Community-Based Nursing and Home Care

MA STAAR Fall Learning Session Real-Time Handover Communication 2:45-4:00PM Breakout Cape Cod Hospital, Hallmark Health System Gail Nielsen, Marian Bihrle-Johnson.

1.semestr Introduction to Clinical Medicine I.. Goals – winter semestr: To take students towards a bed of patient To introduced to health practice To.

A partnership of the Healthcare Association of New York State and the Greater New York Hospital Association NYSPFP Preventable Readmissions Pilot Project.

MA STAAR Learning Session Completing the Transition into Skilled Nursing, Acute Rehabilitation, and Long Term Care Facilities Laurie Herndon and Kate Bones.

MA STAAR Fall Learning Session Early Assessment of Post-Hospital Needs 1:15-2:30PM Breakout Massachusetts General Hospital and Sturdy Memorial Hospital.

The Role of the Nurse Care Manager in Linking Patients with Behavioral Health Resources Care Transformation Collaborative of R.I. TONI L. SCHLAIS RN NURSE.

Care Transitions Program Sherrill Rhodes, MSN, HCAP Divisional Director Quality & Service Excellence Diana Ruiz, DNP, RN-BC, CWOCN, NE Director of Population.

22670 Haggerty Road, Suite 100, Farmington Hills, MI l Save Your Census: Strategies to Prevent Re-hospitalization March 30, 2010 Joint.

{ Care Transitions Program Diana Ruiz, DNP, RN-BC, CWOCN, NE Director of Population & Community Health Medical Center Health System.

MiPCT Embedded Case management Barriers to developing an embedded Case Management program.

Welcome! Please take a seat at any table MA STAAR Learning Session April 23, 2012.

1 Cognitive Impairment and Dementia: What You Need to Know about Alzheimer's Disease and Related Disorders Part 2 – Clinical focus Susan Rowlett, LICSW.

Central Valley Care Transitions Collaborative

Adding Value: New Paradigms in Medical Education Isaac J. Kirstein, DO, FACOI Dean, Ohio University Heritage College of Osteopathic Medicine - Cleveland.

PROCESS MAP TOOLKIT.

Discharge Management Susan Gutierrez RN, BSN, RNC Wake Med Intensive Care Nursery.

Missouri Quality Initiative for Nursing Homes presented by Colleen Galambos PhD Care Transitions Lead Marilyn Rantz PHD Principal Investigator.

Source: AMA: Steps Forward

Interdisciplinary Team Role Play

Medication Reconciliation ROP Compliance

Palliative Care at South County Health

A Resource Toolkit for Engaging Patient

Nursing Facility Research Partnership

Discharge Planning and Transition to Home

Interprofessional Collaboration and Stroke Best Practice

Presenter: Thom Bishop-Miller, LPN

DECREASING HOSPITALIZATIONS IN DIALYSIS PATIENTS

PROCESS MAP TOOLKIT.

Peg Bradke and Rebecca Steinfield

Extending Case Management Using Telehealth

Challenges Innovations Lessons Learned

PROCESS MAP TOOLKIT.

Marcia Levetown, MD, and the Committee on Bioethics

Emergency Department Disposition Support Program Overview

Acute Community Healthcare: Mobile Integrated Health

PATHWAYS MARKETING OVERVIEW

St Peters Hospice Services

Improving Community Health and Wellbeing: Third sector collaboration with rural Out Patient Departments Anne Thomas, Staff Nurse, Out patient Department,

Context Strategic Framework for CCKO

Bridges: Supporting Ohio’s Young Adults Emancipating from Foster Care Chynna Kelly, Ohio Department of Job and Family Services Geoff Hollenbach, Child.

EPA Graphics AFMRD EPA TASK FORCE.

PROCESS MAP TOOLKIT.

Vermont Department of Health

PROCESS MAP TOOLKIT.

Readmission Assessment Tool

PROCESS MAP TOOLKIT.

PROCESS MAP TOOLKIT.

Community Based Palliative Care

Supplementary Data Tables, Organizational Trends

Kathy Clodfelter, MSN, MBA, RN, NE-BC

A view from the sharp end

Welcome! MA STAAR Learning Session April 23, 2012

Volunteer with Fairview Hospice as a

MA STAAR Fall Learning Session Real-Time Handover Communication

Module 2: What is the Role of the Nurse Navigator?

A Facility Approach to Reducing Hospitalizations from the SNF to Acute Care Hospitals September 12, 2019.

Kristen Kroener, MSW, LSW

Chronic Disease Transitional Care Northridge Hospital Medical Center

Amanda Moore - ANP Alex Shaw – Team Manager

PROCESS MAP TOOLKIT.

Presentation transcript:

FORGING PARTNERSHIPS IN THE CONTINUUM OF CARE Lorraine Estep, MSW, LSW Community Liaison to PowerBack Willow Grove and Rydal Park Skilled Nursing

Helping the patient navigate the Continuum

ASSISTING OUR PATIENT WITH TRANSITIONS

Community Liaison Role Accept Referral for Home Care, Palliative, or Hospice Review charts Meet patient; Contact family, Caregivers Confirm demographics, PCP, D/C plan, educate on Home Care services Send referral to Central Intake Department Contact PCP, arrange mobile lab, obtain needed orders, work with SNF transition care team

Adjusting involvement to each patient Minimal Navigation: - Prepared - Educated - No obstacles

Complex Navigation: - Noncompliance - Significant obstacles - Life style changing event

Avoiding disruption to patient’s recovery plan - education - communication - collaboration

Outcome: -Patient returns home -care needs are met -patient is successful