Transitions in Care Program

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Presentation transcript:

Transitions in Care Program Mary Bittner, RN, MPA, CENP, DNP(c) Vice President, Nursing

What is a Transitions Coach? They encourage patients to take a more active role in care They don’t fix problems or provide skilled care They do model and facilitate new behaviors and communication skills They desire for patients to effectively manage care after discharge and independently manage issues Bond, Christinia Pavett; Coleman, Eric. Reducing Readmissions, A Blueprint for Improving Care Transitions.(Chapter 5, pg. 55-58)

Goals for Effective Coaching Patient Empowerment Improved Self-Management Skills Enhanced Patient to Practitioner Communication Strengthened ability to recognize early signs of potential problems Picture of Coaches here Possibly could add picture of the Transition Coaches to this slide.

Dynamic Patient-Centered Approach Medication Self-Management The Four Pillars Dynamic Patient-Centered Approach Medication Self-Management Physician Follow-up Red Flags Would be cool to find a graphic of four columns or pillars then enter the bullets into each one on this slide. http://www.caretransitions.org/structure.asp

Program Operations Transition Coach staffing Tuesday-Saturday Initial patient contact prior to hospital discharge Phone contact within 24 hours of discharge Face to face visit within 48-72 hours of discharge

Phase One Target Population CHF (Congestive Heart Failure) PNA (Pneumonia) DVT (Deep Vein Thrombosis) Reasons: - Chronic Disease in our vulnerable elderly population. - Core Measure focus. - CMS no longer paying for readmissions within 30 days for CHF & PNA.

Target Population Subsequent Program Phases Newly diagnosed chronic disease patients Patients with frequent acute hospital re-admissions and/or multiple E.D. visits Patients with compliance issues and psycho-social challenges http://www.caretransitions.org/structure.asp

Patient Personal Health Record Health & Symptoms Upcoming Provider Appointments & Recent Admissions Questions for Medical Providers Medication List Self Monitoring

Patient Personal Health Record Medical History Red Flags Goals Advanced Directives Important Phone Numbers

PNA Zone Tool

CHF Zone Tool

DVT Zone Tool

Patient Progress Tool

Monitoring Our Progress Patient contact tracking tool Metrics of measurement for 30 days Correlation to Utilization Management Committee readmissions data Evaluation of NRC Picker scores with patient perception of communication and answering questions Please move this slide to the end of the series

Questions?