1. INSPIRED Interventions
Referral Received or patient flagged via EDIS . Meets criteria and lives in HRM. Reasons to exclude might be multiple co-morbidities (that may be best dealt with by other teams i.e. Hgb decreased, CHF, severe heart dysfunction); can be determined by medical director if in question. Send INSPIRED referral to FAX NUMBER (original stays on in-pt chart, Heidi puts in INSPIRED mailbox). Have referral stamped and dated.
Review medical history (use HPF and in-pt chart) to assess eligibility. Meet with patient/family, provide info sheet, business card and RT name. Make chart entry stating “thanks for referral…”, other details ,and include INSPIRED phone #. Obtain signed consent if possible while pt in, if not, obtain consent on 1st home visit (keep consent on INSPIRED chart). .
Note: Patients can technically accept services but decline use of their data (rare and unlikely)  .
Update medical director while patient still in-pt. Provide Hx, allergies, current resp meds (view to optimize), state current antibiotic, prednisone use (leave this info on Graeme’s chair or give to Heidi if GR out). Medical director OR covering MD provides action plan (to be put in INSPIRED mailbox when completed; AP not given to patients until 1st home visit).
Prior to patients’ discharge, obtain photocopies of: Med reconciliation forms (admission and discharge), Discharge Summary, and Action Plan. Place copies on INSPIRED chart, hold original action plan ‘til first RRT visit. .   .
Provide Jillian with name, address, phone number of patient and who will be primary RRT. She will assign an INSP/DART-#.  .
INSPIRED Interventions
RRT contacts patient within 48 hours of discharge to arrange first clinical visit (ideally within 1 week of hospital discharge).Letter to clinicians/HPF if visit: (1) patient refuses service or visit delayed longer than 1 month. Place copies of refused/ineligible referrals and notes Jillian’s in-tray and she will update binder and electronic spreadsheet (for Heidi).  .
First RRT visit: Obtain/confirm signed consent. Visit as per RRT assessment form and intervention checklist. Provide info re: team phone Reinforce importance of GP visits and continuity. Promote that future action plans be completed by GP.
Documentation/Communication for first visit: Document visit in INSPIRED chart and complete required paperwork. Keep intervention checklist on left side of chart and always on top. Draft visit letter and send to Medical Director to proof. Once complete, letter (with electronic signatures embedded) is ed to Heidi. Heidi will print, fax to GP and others, then “chart check” and send to Medical Records for scanning to HPF. Letter/labels place in INSPIRED mailbox. Advise Jillian re: visit #, date, and any other pertinent details.
Phone contacts: All phone “interventions” need to be written on a progress note and sent to HPF as “phone consult”. Copy GP and other clinicians in the patient’s circle of care if appropriate. Advise Jillian of phone contact.
Second RRT visit: Education follow-up, complete interventions as per checklist and complete RT assessment form if not done on first visit. May schedule additional educational visits if necessary. Update team Spiritual Care Practitioner and Jillian when RRT visits are complete.
Documentation/Communication for visit 2: Document 2nd visit in chart (progress note and checklist) and if new issues identified (i.e. visit involved more than following up on disease self-management education) then formal letter needs to go to GP, clinicians, and HPF.
Visits for psychosocial/spiritual assessments and Advance Care Planning: Approximately 2 visits (or more) as per identified need. Documentation/Communication for visit 1: Complete intervention checklist in INSPIRED chart. Complete progress note (written or electronic). Once complete, progress note (with written or electronic signature embedded) is ed to Heidi. Heidi will print, “chart check” and send to Medical Records for scanning to HPF. Letter/labels place in INSPIRED mailbox. Advise Jillian re: visit #, date, and any other pertinent details. Documentation/Communication for visit 2: Document 2nd visit in chart (progress note and checklist) and if new issues identified (i.e. visit involved more than following up on support and ACP) then make sure note is scanned to HPF and other clinicians as required/relevant (letter to GP /others at team’s discretion). If personal directive completed, provide original copy to Jillian. She will copy for: patient’s family (could be more than 1 copy); our INSPIRED chart; HPF; one to include with GP exit letter. Update Jillian when these visits are complete.
Monthly phone follow-up x3 beginning one month after final RRT visit. Complete phone checklist. Advise Jillian when visits/calls are complete. She will send exit letters (including personal directive if completed) to patients, clinicians, and HPF.  .