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Home Health Partnership A collaborative approach to reducing re-admissions
What’s wrong with this picture? Each department may excel in their respective practice, but without communication and collaboration the outcomes may not turn out as anticipated.
The Partnership between ValleyCare and Alliance Home Health Care Ongoing exchange of patient centered information Monthly round table meetings to gain insight into challenges, successes, improvement of practices Telephone, Fax, and Email follow up on cases Shared information between departments to help develop new tools to facilitate continuity of care
Using the same teaching materials in all patient settings Provides continuity and consistency in content once the patient returns to the community setting.
Identifies subtle changes in condition designed to prevent escalation of emergent care. Daily Phone Call Follow-up between skilled nurse visits Using agency specific forms
CHF Alert Form Provides succinct information to the physician to expedite orders or direction to the home health provider
Standard CHF Patient Report A communication tool for physicians who prefer written updates
Handoffs Information exchange with case manager at intake stage At start of care (SOC) – one page physician standing orders for CHF provided to home health agency (HHA) Thorough review of history and physical by hha intake staff Critical information, orders passed on to hha staff caring for patient
Communication Phone Fax In person at care conferences, meetings Supervisor staff review of all documentation from all Home Health disciplines for immediate intervention if needed
Patient discharged without emergent care (38 days on service) and no re-admission • Patient/caregivers knowledgeable and compliant with lifestyle and behavior changes • Patient/caregivers knowledgeable of early intervention/prevention of exacerbation Success Stories
Challenges Non-compliance Severity of disease Communication challenges between providers/ departments, between shifts/weekends
Anticipated Mutual Outcomes Patients remain in the community independent with disease management by the end of episode of care (60 days) if needed. Both providers have thorough knowledge of patient’s condition in real time. Reduction of re-admissions
Take-away Communication and collaboration are vital to the success of patient care from the time the patient walks through the door of the facility until the last clinician leaves the patient’s home
Contact Information Alliance Home health care, inc. 12657 alcosta Blvd. suite 155 San Ramon, CA 94583 Office: 925-275-9300 Fax: 925-275-9304 Dorothy coffey, msn, rn, cnl Administrator/dpcs email@example.com