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Continuum of Care

This presentation will probably involve audience discussion, which will create action items. Use PowerPoint to keep track of these action items during your presentation In Slide Show, click on the right mouse button Select “Meeting Minder” Select the “Action Items” tab

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Continuum of Care

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  1. This presentation will probably involve audience discussion, which will create action items. Use PowerPoint to keep track of these action items during your presentation • In Slide Show, click on the right mouse button • Select “Meeting Minder” • Select the “Action Items” tab • Type in action items as they come up • Click OK to dismiss this box • This will automatically create an Action Item slide at the end of your presentation with your points entered. Continuum of Care Joanne Svogun (Team Advisor) Michael Tassiello Manisha Sheth Yvette Carp

  2. How Our Specific Area of Interest Was Chosen. Michael Tassiello

  3. What We Have Determined So Far. Manisha Sheth

  4. What Needs to Be Done From This Point Forward. Yvette Carp

  5. “What Is a Continuum”?

  6. Continuum Examples McDonalds Drive Thru U.S. Highway System

  7. Initial Definition • Some patients may not flow through the entire continuum of care, resulting in a decrease in revenue and patient satisfaction

  8. Entire Continuum

  9. More Manageable

  10. Goal #1 Determine Which Point in the Continuum to Address

  11. How Do We Get From This

  12. To This

  13. How Our Specific Area of Interest Was Chosen. We Needed a Flowchart to Help Us Better Understand the Present Hospital Continuum.

  14. What If My Daughter Swallows a Rubber Frog?

  15. What Will Be Our Target Area to Examine Within the Rehab Portion of the Continuum. • What happens to patients who leave 8W (inpatient rehab). • Where do they go?

  16. Where Do Patients Go Post 8 West Rehab • 44 % (107) home with home care • 16 % (40) ECF • 16 % (39) home with ACRM • 11 % (28) other • 5 % (13) home w/ other outpatient • 5 % (12) home no services

  17. Where Do Patients Go Post 8 West Rehab

  18. ECF-Extended Care Facility

  19. Our Refined Definition • Due to a lack of formal affiliations with area homecare agencies, patients discharged from inpatient rehab to home care may not flow through the entire continuum of care, resulting in a decrease in revenue and customer satisfaction.

  20. Home With Home Care

  21. Timeline • Goal #2 determine reason for loss to continuum- Mid - May 2005. • Goal #3 all changes implemented - July 2005. • Goal #4 monitoring 3 months post changes – Oct 2005.

  22. What Have We Determined So Far.

  23. How many were able to go directly home from 8W • 72% of patients were able to go directly home from 8West Rehab.

  24. 56% or 20 Patients Lost in The Continuum 53% or 12 Patients Lost in The Continuum 8W Discharges to 2 Target Agencies (April – Oct 2004).

  25. Did Not Need Outpatient Services Did Not Obtain Outpatient Service Despite a Need for Them Went Elsewhere (and Most Importantly Why? Why Were Patients Lost to the Continuum?

  26. Goal #2 determine reason for loss to continuum • Meetings and interviews with: • CT-VNA • Nursing and Home care • Interview Patient: • Who did NOT go to ACRM Outpatient • Who DID go to ACRM • Meetings and interviews with 8 West Staff

  27. Meeting With Home Care Agencies • Discussion • A need for W-10 form faxed directly to them • Need to know patients functional level • Medications • Diagnostic lists

  28. Meeting With Home Care Agencies …contd • In service: • N+HC Staff meet on the 3rd Thursday of each month. Willing to meet with our rehab team on occasion. • Communication & Education: • Interested in our therapists discussing goals, treatment strategies and discharge dispositions for common patients.

  29. Progress toward Goal 2 • Interviewed past inpatient rehab patients who did not go to ACRM outpatients, post home care services.

  30. Results • Patient were NOT always aware of the need and availability of out patient therapy. • Not aware of benefit from a physiatrist consult. • Ortho patients are often seen by there own surgeons and rehab teams. • Few patients go to community based wellness programs.

  31. Interview with patients who went to out patient ARCM

  32. Interview 8 west staff • Discuss discharge instructions

  33. What Needs to Be Done From This Point Forward. Yvette Carp

  34. 8 west inpatient staff In service

  35. Patient/caregiver education Handouts

  36. Home care agencies Periodic Meetings & Education to follow through the continuum.

  37. Implement all changes as determined by our data

  38. Goal #4 – Evaluate the effectiveness • Survey patients for their feedback • Survey Home Care Agencies • Follow up audit of post changes being implemented within three to six months

  39. If our changes help us capture 10% more of the patient lost to the continuum • Increase Revenue = Number of patients x Av. Reimbursement

  40. Can this information be utilized throughout the organization.

  41. Marketing our ideas to make the continuum of care more efficient In house Outside hospital

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