Jay Ford and Collette Croze

1. Overview Jay Ford and Collette Croze OFF

2. A handoff involves the transfer of patient information and primary responsibility between providers.

3. Approaches to Improving Handoffs • Joint Commission • Improve communication • Impact discharge process • Toyota Production System • FEMA • NIATx Model

4. Questions to Consider • Where is the failure • Internal • External • What is the opportunity for improvement? • How will you measure the impact?

5. Joint Commission on Handoffs • Timely, accurate, complete and fully understood information improves patient safety.

6. JCACHO Strategies for Handoffs • Provide handoff in the same order every time; • Use verbal, face-to-face communication; • Allow two-way exchange; • Limit distractions; • Allow others to overhear the information; • Complete patient assessment prior to handoff; • Include the "5 Ps"*--patient name, problem list, plan of care, purpose of plan, precautions.

7. Strategies to Improve Handoff Communication • Use clear language • Incorporate effective communication techniques • Standardize • Create a smooth hand-off between settings • Use technology to your advantage http://ps.mcicvermont.com/appdocs/lps/Strategies%20to%20Improve%20Handoff%20Communication.pdf

8. What is the communication barrier? • Is the message garbled? • Are we exchanging the right information or is it a game of “telephone”? • What type of information is imperative to share vs. nice to know vs. TMI (too much information)? • What is the most effective way to share information?

9. IMPROVING HANDOFFS • Use ‘TEACH BACK’ to assess client’s understanding of discharge instructions and self care • Include family and community caregivers as full partners in assessments and predicting community needs • Coach clients on: • Medication self-management • Use of a client-friendly patient-centered record • Importance of follow up with physicians and clinicians • Knowledge of red flags (signs that the client’s condition is worsening and what to do) Coaching can reduce readmissions by 50%

10. Unit Handoff Tool • Situation • Background • Assessment • Recommendations

11. DISCHARGE PLANNING • Community Support Worker participates in discharge planning • Community staff meet with client 48 hours before discharge ( ALL SYSTEMS ‘GO’) • Specifically identify readmission risk and factors those into discharge plan • Provide customized, real time critical info to the next care provider (THE RIGHT PERSON, THE RIGHT INFORMATION, REAL TIME)

12. San Francisco Hospital Example • Aim: Improve patient transfers to OP medication management clinics • Tool: Toyota Production System • Goals: Improve time of transfer & reduce communication errors • What: Sources of error and delay were identified, and a new process was designed • Results: • Time to process transfer and schedule appointment down 87% • Time to actual appointment down 31% • # of failed handoff down 89% Langley Porter Psychiatric Hospital and Clinics

13. San Francisco Hospital Example • Key principles included: • Specifying the process in detail –the content, sequence, timing and responsible person for each step • Establishing connections between each step • Designing a pathway that is simple • Continuously assessing the outcome and striving to improve

14. San Francisco Hospital Example • Results: • Time to process transfer and schedule appointment down 87% • Time to actual appointment down 31% • # of handoffs per month successfully processed and scheduled up 95% • # of failed handoff down 89% • Have been sustained for 3 years Langley Porter Psychiatric Hospital and Clinics

15. Failure, Mode and Effectiveness Analysis (FEMA) • Assess high risk areas • Analyze processes associated with those areas • Look for potential areas for failure • Seek improvements to reduce failure likelihood

16. Make connections with the next level of care or post-treatment supports: Emphasize the "we" in each person's journey to long-term recovery. Let them know that there are individuals and organizations that can help them to sustain their recovery, and wherever possible, establish personal connections for internal and external referrals. Establish clear two-way expectations and communication between levels of care. The guided tour. Encourage and empower clients to meet with individuals and organizations providing ongoing recovery supports before they leave the facility through participation in the next level of care or recovery support groups prior to discharge. Streamline Paperwork Streamline the paperwork process between the referral source and outpatient program to eliminate duplication of effort. Reward Attendance at the First Outpatient Appointment Give clients a reward when they attend the first outpatient session with a clinician and let them know ahead of time about the reward. Overlap Levels of Care Overlap outpatient treatment with treatment from the referring level of care so that clients have the opportunity to experience outpatient care before being discharged from the referring level of care. Blend Levels of Care Blend other levels of care with outpatient treatment so that clients can develop therapeutic relationships and familiarity with outpatient clients, therapists, and locations before moving to outpatient care. Orient Clients to Outpatient Treatment Provide orientation for outpatient treatment before admission and prior to discharge from a referring level of care Strategies to Ease Client Transitions Between Levels of Care

17. Baseline: 66% No show Change 1 OP staff meet pts in detox No significant effect Change 2 Recovering coaches explain program/invite No shows 37% Change 3 Recovery coaches + calls to remind 1 day prior No shows 30% Change 4 Coaches+calls+detox come as a group when appropriate No shows 26% Manatee Glens-SarasotaDetox to outpatient

18. Baseline: 51% No Shows Change Bundle Outpatient case worker talk to patient + inpatient staff Schedule appointment Identify/remove barriers AM reminder call Current: 25% no shows Georgetown SC - Ruthena ParkerInpatient to Outpatient

19. NIATx Promising Practices • Offer a Tour Guide • Overlap Levels of Care • Blend Levels of Care • Include Family and Friends in Discharge and Admission Planning • Use Motivational Interviewing • Use Video Conferencing • Map Out Continuing Treatment • Orient Clients to Outpatient Treatment • Offer Telephone Support • Reward Attendance at the First Outpatient Appointment