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Clinical Strategies To Improve Patient Outcomes. Care Transitions Between Health Care Providers Christine Stegel RN, MS, CPHQ Performance Improvement Coordinator & Carol Ann Thomas RN, MS, CPHQ, COS-C Manager, Patient Safety and Quality Improvement St. Peter’s Home Care. Objectives.

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clinical strategies to improve patient outcomes

Clinical Strategies To Improve Patient Outcomes

Care Transitions Between Health Care Providers

Christine Stegel RN, MS, CPHQ

Performance Improvement Coordinator

&

Carol Ann Thomas RN, MS, CPHQ, COS-C

Manager, Patient Safety and Quality Improvement

St. Peter’s Home Care

objectives
Objectives
  • Define care transition
  • Describe two evidence-based models for patient care transition
  • Discuss one agency’s experience in improving communication between the hospital and the home health agency
definition
Definition
  • Care transitions are patient transfers from one care setting to another
  • Transitional care includes all the services required to ensure the coordination and continuity of health care as the patient moves between one health care service provider to another
care transition discharge planning
Care Transition - Discharge Planning
  • Referrals are received by fax or by telephone
  • Discharge Liaisons
  • HIPAA
care transition gaps
Care Transition - Gaps
  • Communication gaps

- Physician

- Referral process

  • Patient self-management
  • Care coordination
  • Medication
care transitions
Care Transitions
  • Two evidence-based care transition models
    • Dr. Eric Coleman’s “Transition Coach”
    • Dr. Mary Naylor’s use of an Advance Practice Nurse
care transition model dr eric coleman
Care Transition Model- Dr. Eric Coleman
  • Patient self-management

- Medications

- Know of signs of worsening condition

  • Personal Health Record
  • Primary Care Physician follow-up
  • Transition Coach
care transition model dr eric coleman8
Care Transition Model- Dr. Eric Coleman
  • Patient Self-Management
    • Knowledge of medication – actions, side effects, and interactions
    • Medication management method
    • Medication reconciliation when patient returns home
    • Knowledge of signs of worsening condition
care transition model coleman
Care Transition Model - Coleman
  • Personal Health Record
    • Demographic information including Primary Care Physician & caregiver contact information
    • Medical history
    • Medication list & allergies
    • Checklist of activities that are needed prior to discharge
    • Area for patient’s health care questions
transition model coleman
Transition Model - Coleman
  • Transition Coach
    • Facilitates interdisciplinary collaboration
    • Ensures continuity of care
    • Supports patient self-management activities
    • Encourages the patient to take a more active role in their disease management and care decisions
transition model coleman11
Transition Model - Coleman
  • Care Transitions Measure – measures the extent patients are being prepared to participate in post hospital self-care activities

Source: www.caretransitions.org

care transition model dr mary naylor
Care Transition Model- Dr. Mary Naylor
  • Advance Practice Nurse
  • Identification of high-risk factors
    • Multiple chronic conditions
    • Evidence of depression or cognitive impairment
    • Patient rates their health as poor
    • Concerns with social supports
    • History of re-hospitalizations
transition model naylor
Transition Model - Naylor
  • Early identification of problems
  • Collaborations with all care providers
  • Continuity of care
  • Utilizes frontloading of visits with telephone calls
    • APNs are expected to use their clinical judgment
transition model naylor14
Transition Model - Naylor
  • Strategies
    • Face to face interaction with the Physician while in hospital and then at first follow-up visit – ability to develop a relationship/trust
    • Medication reconciliation
    • Early symptom management
summary similarities between the two models
Summary – Similarities Between the Two Models
  • Used with patients who are complex/fragile
  • Continuity of care between settings
  • Interdisciplinary collaboration
  • Medication reconciliation
  • Regular timed follow-up post hospitalization