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Transitions of care in the rural setting
Sleepy Eye Medical Center
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Presenters Wendy Borth, BSN Sara Schultz, RN
Wendy received her BSN from Mankato State University. She has 17 years’ experience as a charge nurse, including working in OB, ER,, and surgery. She then obtained certification as a Certified Hospice and Palliative Nurse and worked as Hospice Care Coordinator for 14 years and also Home Care. Wendy developed and coordinates the Transitional Care Management Program (TCM), as well as leading the clinic to obtain Health Care Home Certification in 2015. She is presently the TCM nurse, Health Care Home Coordinator, Utilization Review Nurse, member of the Compliance, Medication reconciliation, CQI, and Patient Safety Teams. Sara Schultz is a Registered Nurse at Sleepy Eye Medical Center, there she works as the Quality Improvement, Patient Safety and Patient and Family Advisory Council Coordinator. Sara has been a committed employee of the Sleepy Eye Medical Center for 5 years in which she has worked in various positions: Clinic LPN, Outreach Lead Nurse and functions as a backup for many other areas. She graduated in 2012 from Rochester Community and Technical College with a diploma in nursing and in 2015 from Excelsior College with an Associate’s Degree in Nursing.
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Sleepy eye medical center
Outpatient Services: Emergency medicine Diabetic teaching IV therapy Lactation counseling Pathology Same day clinic visits Same day surgery Transitional care management Rehabilitative Services: Cardiac rehabilitation Occupational therapy Physical therapy Respiratory therapy Speech therapy Outreach Services: Podiatry Orthopedics Urology Cardiology Inpatient Services: Coronary care Discharge planning Hospice Medical Nursery Obstetrics Surgery Swing bed Surgical Services: Cesarean sections Endoscopy General surgery Laparoscopic surgery Orthopedic/arthroscopic Podiatry Urology Diagnostic and Imaging Services: Bone densitometry Cardiac tests CT scans Echocardiograms Holter and event monitoring Imaging Laboratory Lung cancer screening MRI Mammography screenings Newborn hearing screenings Nuclear medicine Pulmonary testing Sleep studies Ultrasounds X-ray Sleepy eye medical center Main Campus- Sleepy Eye, MN Population: 3,503 Hospital Beds: 16 Clinic Rooms: 14 Providers: 6 MD’s and 1 NP
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Emergency care for stroke patients
As soon as we are notified of a possible stroke, our emergency team prepares for the patients arrival. Our team will work together to: Connect with a stroke neurologist at Abbott Northwestern Hospital’s certified comprehensive stroke center using our Telestroke video technology equipment Perform necessary tests Complete a head CT scan Work with a stroke neurologist to evaluate stroke symptoms Administer clot busting medications, if necessary Arrange for air transportation to a stroke center if advanced care is needed. Emergency care for stroke patients As a designated Acute Stroke Ready hospital, Sleepy Eye Medical Center is prepared to evaluate, stabilize and provide emergency treatment to patients with acute stroke symptoms.
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It is important to know how to spot a stroke quickly and call 911 right away. Time is critical for stroke patients. You can recognize the signs and symptoms of a stroke by remembering B.E. F.A.S.T.: B- Difficult with balance E- Problems with vision in one or both eyes F- Facial droop/numbness A- Arm weakness S- Speech difficulty T- Time to call 911 Patient education The Sleepy Eye Medical Center provides information to patients and the community via the website to stress the importance of knowing how to spot a stroke quickly and calling 911 right away.
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Sleepy Eye medical center statistics
Average time from admission to transfer: 94 minutes Average time from admission to CT: 13 minutes Average time from CT completion to CT read: 22 minutes Average time from admission to administration of TPA (if indicated): 44 minutes Sleepy Eye medical center statistics 7- Emergency Department STROKE admits 4- Transferred to a tertiary care facility
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Therapy care Physical Therapy Occupational Therapy Speech Therapy
Bed Mobility Transfers Gail Balance Coordination Neuro Re-education Lower body strength Use of assistive devices Occupational Therapy Upper body strength Grooming Toileting Hygiene Dressing Bathing Use of adaptive equipment Cognition testing Speech Therapy Speech Swallowing Diet recommendations Alternative communication methods Therapy care Physical Therapy Occupational Therapy Speech Therapy
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Transferred to Tertiary facility
Patient presents to the ED or admitted via inpatient Patient transfers to tertiary facility Wendy follows-up, makes contact with Social worker in neurology department (where patient was transferred) Plan of care information provided and shared Wendy reminds them that upon discharge SEMC offers PT, OT, ST and can provide TCM if notified within 2 business days of discharge. Transfer follow-up Transferred to Tertiary facility
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Discharged to Home/Nursing Home
Discharged to Nursing Home/Home Patient is discharged Wendy follows-up makes contact Plan of care is provided and shared (NH provides therapy) Once patient is discharged from the NH Wendy then provides transitional care management Transfer Follow-Up Discharged to Home/Nursing Home
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Transitional Care and continuity
Transitional Care starts with an interactive phone call within 2 business days post discharge. In home visits available Regular Check-In’s Transitional Care lasts for 30 days, once those 30 days are completed and the patient still requires some assistance, a referral is made to Care Coordination Transitional Care and continuity That first interactive phone calls involves a discussion regarding: How are they doing? Do they have any immediate questions post-discharge? Were there any medication changes a Medication Reconciliation If they have many concerns, I will offer them an in-home visit During that in home visit we go over safety, medication set up and if there is any additional equipment or services that they may need Life-Line Meals on Wheels Home Care Regular Check-in's occur once a week in which I call patients and ask about follow-up appointments (results, medication reconciliation), ask how they are doing, related to discharge diagnosis and if they are doing well or if they would find an added service beneficial Care coordination gives the patient some extra assistance in planning and dealing with difficult diagnoses. The patients work with THEIR care team- provider, nurse and care coordinator to meet their goals or meet action statements in their care plan.
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Gaps in Continuity Bigger facilities prefer to keep patient in systems
Convenience for patients (local) Familiar faces EMR’s do not talk to each other (no standardized EMR) Gaps in Continuity
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Patients are with their primary care clinics and providers for follow-up appointments and rehabilitative services Triple Aim- Patients are more satisfied Regular provider Familiar faces Close to home Quality Services for potential referrals (ST, OT, PT) available Cost Reduced readmissions (due to post stroke complications, falls, non-compliance with medication changes) with close follow up with Transitional Care Management and Care Coordination, continuity of care. Success How this has worked to benefit our patient population– 4 stroke patients transferred out
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