Getting Different Results: Patient Care Facilitator Role Insanity: doing the same thing over and over again and expecting different results. ~ Albert Einstein~

RN practice: 2006 Average task time 3.1 minutes Average task time 3.1 minutes Interrupted mid-task 8 times per shift Interrupted mid-task 8 times per shift 31-44% of time on direct care 31-44% of time on direct care 34-49% on coordination-related activities 34-49% on coordination-related activities Tucker, A., Spear, S. Operational Interruption in Hospital Nursing. Available at Accessed October 7,

PT/OT Resp.Therapist Patient Access Chaplain Anesthesiologist Pharmacist Environmental Srv Nuclear Medicine Cath Lab Diagnostic Srv EKG Transport Plant Ops H.I.M Central Supply Consulting Dr. Residents Laboratory I.T. Radiology Speech Therapy Dietician Clinical Trials Host/Hostess Bio Med Clinical Nurse Specialist Blood Bank Attending Nursing Students Med Students Care manager Consulting Dr. RN C.N.A Consulting Dr.

RN: Plan for the DAY Most similar to current staff nurse role Bedside cares, treatments, caring moment Reports to Nurse Manager RN: Plan for the STAY Coordinate, facilitate & oversee patient’s care Enhance team communication Consistent face to patient Reports to Nurse Manager.

High Expectations  3 years recent acute care experience  BSN  MSN must be obtained in defined timeline  Certification to be obtained if not current  Great collaborator and communicator

Interdisciplinary Team Leader Coordinate plan of care for patient stay. Transition plan (discharge) Round with physicians Lead interdisciplinary rounds Patient Care & Advocacy Navigator Patient Education Transition education and readiness Post discharge phone calls Educate patient/family re: options Plan of care Monitor & assure progressing toward readiness for next LOC Arrangements for next LOC if needed Keep patient/family involved in plan of care. Educate care givers on plan of care Strategize to reduce LOS Outcomes Manager Risk assessment & reduction Monitor and trend outcomes measures Readmission data Implement strategies to improve outcomes Leadership Staff education Provide input into performance evaluation Regulatory compliance Supervises nursing practice Change agent and mentor to frontline caregivers Professional Practice Expert practitioner Implements evidence based practices

Patient Care & Advocacy Navigator Navigator Patient Education Patient Education Transition education and readiness Post discharge phone calls Educate patient and family regarding options

Outcomes Manager Risk assessment & reduction Monitor and trend outcomes measures Readmission data Implement strategies to improve outcomes

Plan of care Monitor & assure progressing toward readiness for next level of care Arrangements for next level of care if needed Keep patient and family involved in plan of care. Educate care givers on plan of care Strategize to reduce length of stay

Interdisciplinary Team Leader Coordinate plan of care for patient stay. Transition plan (discharge) Round with Physicians Lead interdisciplinary rounds

Professional Practice Expert practitioner Expert practitioner Implements evidence based practices Implements evidence based practices

Leadership Staff education Staff education Provide input into performance evaluation Provide input into performance evaluation Regulatory compliance Regulatory compliance Supervises nursing practice Supervises nursing practice Change agent and mentor to frontline caregivers Change agent and mentor to frontline caregivers

Physician Perspective

PT/OT Resp.Therapist Patient Access Chaplain Anesthesiologist Pharmacist Environmental Srv Nuclear Medicine Cath Lab Diagnostic Srv EKG Transport Plant Ops H.I.M Central Supply Multiple consults Residents Laboratory I.T. Radiology Social Worker Speech Therapy Dietician Clinical Trials Host/Hostess Bio Med Clinical Nurse Specialist Blood Bank Attending Nursing Students Med Students Care manager

Readmission Feb – Jan IA Health System IA Health DSMMWH All Cause Readmission Rate - Rolling 12 Months 12.4% 8.4% ALOS - Initial Discharge ALOS - Readmission Outcomes

Cases Days ALOS Length of Stay Primary Hip & Knee Replacement Implemented PCF role 11/2009

MWH Inpatient HCAHPS Dec Feb 2012 Percent ALWAYS MWH Percentile Ranking ALL PG facilities (N=1776) Rate Hospital % 93 Recommend Hospital90% 97 Communication with nurse83% 85 Pain81% 97 Communication about meds71% 91 Discharge91% 94

“Good care coordination will be the key to success with ACO’s” Dr. Mark Purtle, MD, VPMA, IHDM

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