Safe Transitions Of Care STOC 2011 MHA Pilot- 4Q 2010 Transition responsibility belongs to the sending clinician/organization, until the receiving practitioners confirm assumption of responsibility

Learning Objectives 1.Explain 2 reasons why safe transitions of care is important. 2.List the 4 metrics Fairview Northland has chosen to monitor in 2011, and our performance goal. 3.Explain your role and responsibility in this process.

Why is Northland participating? Safety – safe patient hand-off, self care Satisfaction- pt/family, partners Cost- readmission Mission- Patients 1 st, Community Health, Clinical Quality

STOC – Improvement Scope

Transitions = Hand-Off Transferring Facility Contact Person Phone # Fax # Receiving Facility Contact Person Phone # Fax # Primary & Secondary Diagnosis Problem List Allergies Falls Risk Infection/Isolation Mental Status Behavior Status Pain Assessment Skin Assessment Communication needs Code Status Goals- Overall Progress Immediate FU Needs- procedures/lab/tests Special Diet DC Medications Labs Last 24 hrs pertinent test results & pending Core Elements Receiving facilities complained they did not have crucial information &/or could not easily locate it (multiple pages).

Satisfaction: Discharge In your opinion, was the patient and family satisfied with the transition process? In your opinion, were staff at the receiving facility satisfied with information communicated during the transition? Critical to Success :  Response time = now  Satisfy every request in one call  Anticipate needs during prep Critical to Success :  Response time = now  Satisfy every request in one call  Anticipate needs during prep

Cost: Readmission Frequency 12 month period, 4Q 2009 – 3Q 2010 Northland is lower than QUEST best practice peer group

Mission: Community Reputation Transition Stories Make a Difference Every Transition Is a Story In the Making Inpatient Satisfaction- 2010

Performance Measurement- Review What’s Important? Each Patient Transfer has a 4 point opportunity, each pass/fail. 1 point = All Core Elements addressed in transfer information 1 point = Receiving facility scores satisfaction as positive 1 point = Family/patient satisfaction is positive 1 point = Patient not readmitted within 30 days of discharge How is it Reported? 5 = Greater than or equal to 80.0% 4 = Target = = = Less than or equal to 49%

Your Role- Discharge Prep Social Workers Investigate SNF bed options when probability is d/c to NH Obtain bed placement when final discharge plan communicated Write DC date on white board in patient room Coordinate discharge time with RN Care Manager & Charge Nurse Determine transportation and pick up time Write pick up time on white board in patient room Communicate pick up time via pager to charge nurse/care manager Determine LOS/approximate date of discharge Notify care team of discharge date and treatment plan Complete discharge orders in EPIC Sign orders electronically Complete Discharge summary Hospitalists

Your Role- Discharge Prep Charge Nurse Obtain notification of discharge date/time via interdisciplinary care team Review discharge orders and medication reconciliation for accuracy and completeness Verify that medication orders have NOT been sent to local pharmacy Communicate readiness of patient for transfer to Nursing Station Attendant when discharge checklist is complete and information is available to fax Obtain notification of discharge date/time via interdisciplinary care team Complete discharge navigator/discharge profile Communicate completion of patient profile within discharge navigator to charge nurse Complete verbal report to NH staff prior to patient leaving facility Prepare the patient for discharge Complete all discharge documentation via discharge navigator Case Manager RN Fax After Visit Summary and Medication Orders after notification of readiness by Charge Nurse- DO NOT FAX until “green light” from charge nurse. Place After Visit Summary and all other documents in transfer envelope Follow-up appointments?? NSA

Performance Measurement What’s Important? Each Patient Transfer has a 4 point opportunity 1 point = All Core Elements addressed in transfer information 1 point = Receiving facility scores satisfaction as positive 1 point = Family/patient satisfaction is positive 1 point = Patient not readmitted within 30 days of discharge

Performance Measurement

Social Worker Responsibilities 24 hours after transfer – our FN Social Worker contacts the nursing home SW to inquire about patient/family satisfaction. Satisfaction is indicated on a 5 point scale CN section of the form not shown

Charge Nurse Responsibilities Prior to releasing the patient, complete the Discharge Checklist. All Core (required) element must be included.

Performance Measurement

Performance Results/Reporting Initial Performance Data- February 2011 Clinical Practice Director Receives & Reviews all cases Quality Director Scores and Reports graph/data Sent to your manager RESULTS- Progress to Goal January = 71% February = 76% Opportunity for improvement: Improve Core Element communication

Are we able to do More? Project RED 1.“Teach-back” methods 2.End of Life plans 3.Multidisciplinary care coordination 4.Transitional Care Model 5.Comprehensive DC Plans 6.Schedule FU appointments 7.Coach- Med Management What do you think? During Hospital - Discharge - Post Discharge 8.Home visit 9.Call Back & FU 10.Maximize My Chart (PHR) 11.Community Networks (websites) 12.Telehealth monitoring (eICU)

Safe Transitions Of Care STOC Thank You We are Just Getting Started