1. Breakout A: Ensuring Post-Hospital Care Follow-up Linda Campbell, RN VP, Quality & Patient Safety Natalie Kenney, RN Home Care, Heart Failure Nurse Specialist, Transition Care Nurse MetroWest Medical Center MetroWest Home Care & Hospice

2. Community Partnerships Community Partners in the MetroWest area: – Local LTACs and SNFs – – Evercare – BayPath Elder Services – Community Physician Practices Bethany Health Care Center Carlyle House Kathleen Daniels Healthcare Kindred Healthcare MaryAnn Morse Nursing & Rehab Center Oak Knoll Nursing Center River Bend Nursing Center St. Patrick’s Manor Timothy Daniels House Wingate Healthcare

3. Telephonic Care – Post-discharge 09/2010 - Post-discharge telephonic care program instituted for HF pts. 01/2011 - Project expanded to include AMI & Pne Identification methodology, via electronic daily file: – HF – disch from ED to Inpt. with certain Dx codes, “lasix given”, BNP > _ – AMI – Disch from ED to Inpt. with certain Dx codes, Troponin > _ – Pneumonia – Disch from ED to Inpt. with certain Dx codes, CM recommended Abx given

4. Community Partnerships Call program Piloted with one local SNF Expanded Community Partnership concept to include an Educational Collaborative with local LTACs & SNFs Partners identified through Case Management major referral patterns 3 face-to-face meetings since early 2011 3 defined workgroups – Education – Clinical Care – Communication

5. Education Program Standardized Education Program developed Inpt. teaching tools adapted for LTAC & SNF Education provided to 7 facilities, 152 total participants – 110 licensed staff, 42 CNAs Focus on Early Recognition of symptoms and Treat in Place Teaching tools included INTERACT & SBAR tool

6. Clinical Care Need for coordinated care into the Community Workgroup to develop coordinated Plans of Care / Clinical Pathways / Care Protocols First for Heart Failure, then other Dxs Target date for completion – 11/1/2011

7. Communication Workgroup to include hospital IT rep, Case Management, Community reps Address electronic communication – – Use of CuraSpan – auto packet of info to go from hospital to facilities upon discharge Explore other communication options

8. Process/Outcome Data 30-Day All-Cause Readmissions for HF Patients

9. Lessons Learned Teaching Program – Originally presented to mixed audience of licensed staff and CNAs – Refined to program for licensed staff given by Home Care RN; CNA program presented to facility Staff Development as Train-the Trainer for CNAs It takes a Village

10. Next Steps Continue to Partner with Facilities Develop Community Physician Partnership Engage everyone!!!