1. Building Healthiest Communities By Aligning Forces For Quality (AF4Q) A Community Collaboration

2. Building Healthiest Communities: AF4Q

3. Our Contribution: Improving Care Transition Management Building Healthiest Communities: Aligning Forces For Quality (AF4Q)

4. Building Healthier Communities: Care Transition Management TRANSITIONS  a. Passage from one state, stage, subject, or place to another; b. Movement, development, or evolution from one form, stage, or style to another.  To integrate care systems between the hospital and community providers as the client transitions.

5. Building Healthier Communities: Care Transition Management GOALS. The three areas of focus in the AF4Q Collaborative mirror the three primary strategic goals of the St Joseph Health System. 1. Perfect Care 2. Sacred Encounters 3. Healthiest Communities

6. Building Healthier Communities: Care Transition Management Quality Improvement  Primary focus = improving coordination of service as patients move across the continuum of care.  Continuum of care refers to levels of service intensity includes primary care, acute care and home care.  Problems occur most often in the “hand offs” between service providers.

7. Building Healthier Communities: Care Transition Management Quality Improvement  Improving coordination = better outcomes, appropriate utilization & decreased costs.  Focus coordination between the hospitals and the Primary Care Provider (PCP) network.  Challenge: PCP don’t see their own pts in the hospital = need for transition management.

8. Building Healthier Communities: Care Transition Management Quality Improvement  Main reasons for hospital readmission: 1. Lack of Follow Up with PCP 2. Medication Management problems 3. Not knowing when to seek help 4. Lack of Follow Up on tests and treatments.

9. Building Healthier Communities: Care Transition Management AIM  To improve client outcomes (clinical & quality of life) in transferring from one care setting to another.  To provide a new area for collaboration between St Joseph Hospital and Humboldt State University for nursing education.  To ensure that all hospitalized patients receive some kind of follow up contact upon discharge..

10. Building Healthier Communities: Care Transition Management What Is It? Free service to any hospitalized client. Facilitates development of clients to be “co-managers” of their health needs. Sustainable platform for: Patient Empowerment Patient Empowerment Health Care Self- management Health Care Self- management Self-advocacy skills Self-advocacy skills

11. Building Healthier Communities: Care Transition Management MODEL BASIS Coleman Transition Intervention Model Transition Coach Role: Advocate versus “Doer”Role Advocate versus “Doer”Role Promotes Self Reliance & Promotes Self Reliance & Self Management Self Management of Healthcare Needs

12. Building Healthier Communities: Care Transition Management MODEL BASIS Coleman Transition Intervention Model Four Pillars of Service 1. Personal Health Record 2. Medication Record 3. Red Flags 4. Follow-Up Needs

13. Building Healthier Communities: Care Transition Management MODEL BASIS Coleman Transition Intervention Model 1. Follow up service for 120 days 2. Ensure clients are connected with PCP network 3. Build skill sets of clients & care providers

14. Building Healthier Communities: Care Transition Management Conclusions 1. Quality of care is improved by facilitated transitions. 2. Readmissions & unnecessary utilization of resources are decreased with client coaching 3. Strengthening linkages between PCP network & hospitals prevents adverse outcomes & improves client experience.