1. Our ARC Journey…Professional Home Care Associates Cheryl Haynes RN BSN Nursing Supervisor

2. Brief History: Feb 2009- Valley Care shared their educational material for CHF with agency March 2009- Started post discharge collaboration Jan 2011- First ARC meeting with Valley Care Feb 2011- Joined CHF PI team at Valley Care March 2011- Started weekly case conferences on CHF patients with home care staff. April 2011- Developed “CHF Red Flag” form April 2013- Developed D/C review tool

3. How We Connect to the Transitions Team at Valley Care: Weekly reports faxed to transition coach Phone calls as needed Ongoing support from Transition coaches with trouble shooting for complex/high risk cases Attend monthly PI meetings at hospital

5. What is the process during Handoffs?

6. The Process is simple: T.C. from D/C planner about CHF referral & indicates patient is “CHF Protocol” Home care receives H&P, updated D/C medication list, & orders Intake coordinator communicates with Home RN that pt. is “CHF protocol” & gives copy of educational material to RN Patient opened to home care day after hospital D/C (day 1) Weekly reports faxed to Transitional coach until patient reaches day 30

7. What Processes are Used to optimize communication? Transitional Coach can call directly to RN following case (especially if coach is having trouble contacting pt. by phone) Developed communication tool to MD- “Patient visit report” – Support/reinforcement by MD to pt/family – Patient/family hearing same information from medical team Developed “CHF Red Flag” form to improve MD response time for patients showing symptoms

10. Success: CHF Red Flag form – Improved MD response time CHF report form – Stream line reports from field RN’s

11. Challenges: Weekly case conferences before using report form. Timely MD responses before “red flag” form End of life issues/high risk patients Social issues Pt/family “buy in” regarding teaching

12. Key take home messages: Be patient…process doesn’t happen overnight! Customize your process that will be feasible to your particular agency/hospital needs Anticipate making changes to your process as you move forward….things don’t always go as planned.

13. Outcomes: Current CHF readmission rate is 19% Now using D/C review tool to study reasons/trends in readmissions. Plan- expanding program to other diseases (MI, Pneumonia)

14. Questions?? Contact information: – Cheryl Haynes RN BSN – Professional Home Care Associates – (925)243-1385 or email chaynes@prohomecare.com