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Same Page Transitional Care
Heidi Gil, NHA, CCM Planetree Senior Director of Continuing Care Michael Lepore, PhD Planetree Director of Quality, Research, & Evaluation Same Page Transitional Care
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Inspiration for Project
Activation of patient & caregiver 24-hour, patient-directed visitation Care partner programs Access to Information Open medical records Resource Library Bedside rounding Many patients experience uncoordinated & chaotic transitional care, leading to high costs & frequent unnecessary readmissions Patients discharged from hospitals to nursing homes are sicker & more likely to be re-hospitalized than community-dwelling patients SG In Planetree focus groups over the years, patients have been asked “What would make your hospital experience more healing?” Common response: Access to family and friends Designation criteria reflect this with a number of criteria that relate directly to family’s presence and involvement Results of a random survey of 4500 adults who were asked: “How interested are you in reading your own medical record?” 79 % were interested in reading their medical record Most common reasons to want to read the chart: To be more involved in their health care (74%) To see what the physician said about them (74%) To understand their condition better (72%) Fowles, 2004 Angelica Thieriot, Planetree’s Founder 1978
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Same Page Transitional Care
Same Page Transitional Care is intended to assure that patients, their informal caregivers, and healthcare providers across settings, particularly hospitals and nursing homes, are on the ‘same page’ with regard to patients’ health and healthcare needs, and that this ‘page’ is grounded in patient-reported measures. Socio-Technological Approach Social: Support active engagement of informal caregivers (e.g., friends, family, volunteers) through hospital and nursing home Care Partner programs Technological: Support active engagement with patient-generated information through utilization of the How’s Your Health family of web-based surveys
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Resources for Patients, Families, & Providers
Two informational videos: Patients & Care Partners Healthcare Professionals Videos introduce the Care Partner concept and motivate patients and healthcare professionals to engage Care Partners in healthcare processes Addresses Common Questions about Care Partners: Why a Care Partner? What does a Care Partner need to do? Do Care Partners actually need to give care? How does the Care Partner program work? Is there a best time to select a Care Partner? What are the benefits a Care Partner program? Informal care supporters, such as volunteers or patients’ family members or friends, who support patients in coordinating care Care Partners
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Resources for Patients, Families, & Providers
Two informational videos: Patients & Care Partners Health Professionals Videos introduce HYH, educating and motivating patients, Care Partners, and healthcare professionals to utilize this resource Web-based and iPad-friendly health survey Completed by patients (with help of Care Partners as needed) Provides actionable information to promote health & well-being Facilitates key healthcare stakeholders being on the ‘Same Page’ with regard to the patients’ needs and lifestyle How’s Your Health
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Resources for Patients and Care Partners
Concise compendium of resources given to patients and Care Partners while in the hospital Introduces How’s Your Health Survey Reinforces role of patient and Care Partner as part of care team Provides practical guidance to patients and Care Partners on managing their health and care across settings and with multiple providers
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Measurement and Evaluation
Nursing Home Hospital Sequenced Control–Intervention Design Patient Activation Measure (PAM) Care Transitions Measures (CTM-3) Additional items Health Confidence (ability to manage health problem) Social Support (availability of support when needed) Pain Emotional Well-being Financial Well-being PAM 8: “I understand my health problems and what causes them”
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Thank You Admission Bedside Communicate Daily Life Enlist
Care Stage Process Resources Individuals Admission Identify Care Partners Care Partner Brochure Patient, Care Partner, Volunteers, Admissions Bedside Introduce HYH (Day 2) Use HYH (Day 3) HYH Notebook; Laptop & Printer Patient, Care Partner, Volunteers, Care Team Communicate Use HYH info within & across care settings HYH Portable Record Daily Life Achieve sustainable health & well-being NTOCC Toolkit Patient, Care Partner Enlist Recruit & prepare volunteers & care team HYH & Care Partner Videos & Resources Volunteers, Care Team Care Stage Process Resources Individuals Admission Bedside Communicate Daily Life Enlist Lessons Learned Five Key Stages of Same Page Transitional Care Admission Bedside Communicate Daily Life Enlist
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