1. Improving Patient Transitions: Building Social Networks across the Care Continuum Suneela Nayak, MS RN Nan Solomons MS Shelly Shibles, BSN RN

2. Learning Points Focus on Avoidable Readmissions: Why now? How do social network theories help nurses improve safe patient transitions?

3. Why Now? Avoidable readmissions :  Frequent & costly  Issue of quality of care and patient safety  Source of dissatisfaction  Waste increasingly scarce resources

4. Focus on Reduced Readmissions… Offers Abundant Opportunities for Nurses to Advocate for patient’s agenda for care Focus on safety, improved outcomes Develop ability to network across continuum Fully engage clinical skills, scope of practice

5. MaineHealth Transitions of Care Bundle 1. Risk stratification for readmission 2. Transition Checklist 3. Medication reconciliation 4. Patient/family health education 5. Timely communication among hospital and post-hospital providers 6.Timely follow-up of patients

6. Leading with Innovation What are Social Network Theories?

7. Social Network Theories Social networks consist of: nodes (people) ties (relationships)

8. Social Network Theories S Isolate Boundary Spanner Strong Tie Weak Tie 2-way 1-way Incoming tie Outgoing tie

9. Social Network Analysis Home Health SNF LTC PCP Specialty Social Services ED Pharmacy Discharge Planner Hospital Med- Surg Records

10. Leading with Innovation How do Social Network Theories Help Nurses Improve Patient Transitions?

11. Evolution of Our Team WMHC Cross- Continuum Team (Expanded) Stephens Memorial Hospital Transitions Team Cardinal Health Grant Team WMHC Cross- Continuum Team 2009201020112012

12. 2009 Stephens Memorial Hospital: Cardinal Health Grant Team MaineHealth SW OT QI Care Transitions Coach Physician Practice 1 PT RN Hospice RN Mgr H-H IT Rx Acute Care Group Cardinal Health Team

13. 2010: Stephens Memorial Hospital TransitionsTeam SW OT QI CT Coach Physician Practice 1 PT RN Hospice RN Mgr H-H IT Rx Dir, LTC Patient Care Facilitator LTC RN Stephens’s Memorial Hospital Transitions Team Acute Care Network MaineHealth

14. Improving Transitions: Next Steps 2011: CMS quoted the SNF Readmission Rates at 19.8% Next Step:  Network with regional Long Term and Skilled Nursing Facilities

15. Western Maine Long Term Care Network Physician Practice 2 Physician Practice 1 Long Term Care Network

16. 2011: Western Maine Cross Continuum Network SW OT QI Care Transitions Coach Physician Practice 1 PT RN Hospice RN Mgr H-H IT Rx Director LTC Patient Care Facilitator RN, LTC Physician Practice 2 MaineHealth

17. 2011: Western Maine Cross Continuum Network Ties Stephens Memorial Hospital Transitions Team HomeHealth & Hospice Long Term Care Admin & Staff Physician Practice 1 Physician Practice 2 CT Coach MaineHealth

18. Our Transitions Team Today: Increased:  Comfort  Trust  Teamwork attributes  Engagement  Ease of referral  Social Worker invited to travel to nursing homes  Meetings run over time, no one leaves  Daily phone conversations for early problem solving

19. Our Next Steps… Who else should be at the table?

20. 2012: Western Maine Expanded Cross Continuum Network Acute Care Team HomeHealth & Hospice Long Term Care Admin & Staff Physician Practice1 Physician Practice2 Care Transitions Coach EMS Patient MaineHealth EMS

21. So… How has all this improved outcomes for our patients?

22. MaineHealth Readmission Rates: Outcome Measures

23. Questions? Suneela Nayak, MS RN Nan Solomons MS Shelly Shibles, BSN RN Improving Patient Transitions: Building Social Networks across the Care Continuum