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Patient Engagement through Patient Centered Goals

Patient Engagement through Patient Centered Goals. Chris Walker MSN, RN, MHA St. Cloud Hospital/CentraCare Health. Typical Transition Failures. Self-care Care Planning Health Literacy/Communication. Improvement Strategies. Self-care Care Planning

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Patient Engagement through Patient Centered Goals

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  1. Patient Engagement through Patient Centered Goals Chris Walker MSN, RN, MHA St. Cloud Hospital/CentraCare Health

  2. Typical Transition Failures • Self-care • Care Planning • Health Literacy/Communication

  3. Improvement Strategies • Self-care • Care Planning • Health Literacy/Patient-Provider Communication

  4. Illness Management & Recovery(IM & R) • Psychoeducation • Behavioral tailoring for medication adherence • Relapse prevention training • Coping skills training • Social skills training

  5. Recovery Goals • Unique to each individual • Must be personally meaningful • Vary from modest to ambitious • Use of Motivational Interviewing (MI)

  6. Unique Treatment Plan (UTP) • Criteria and types • Plan development with patient and interdisciplinary team • Electronic health record access

  7. Interdisciplinary Staffing Note • RN/SW Communication • Plan of care Day of IP stay • Payor UTP (yes/no) • Suicide risk assessment Violence risk assessment • Event changes Family meeting • Illness, Management & Recovery (IM & R) • Recovery goal • Dialectical Behavior Therapy Protocol • Behavioral Chain Analysis • Diary card • Integrated Dual Disorder Treatment (IDDT) • Staged within 3 days of admission • Stages of mental health and/or substance use • Transition Plan • Disposition needs • Medical follow up

  8. Bedside Shift Report • Warm handoff • SBAR report • Focused pt and safety assessment • Review of tasks • Identify patient and family needs/concerns

  9. My Care Board

  10. Managing My Recovery • Relapse prevention plan • Reasons for living • Possible triggers • Early warning signs • Support people • Recovery goal • Strategies for success

  11. Discharge Checklist • Specific to disciplines • Improved consistency

  12. Transforming Care at the Bedside (TCAB) • Purpose • Rapid change cycle (PDSA) • Positive culture change

  13. References • www.rarereadmissions.org • Nurse Bedside Shift Report. June 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/hospital/engagingfamilies/strategy3/index.html • Meyer, P. & Gingerich, S. (2009). Supporting Illness Management Recovery on Inpatient Units. • 2007: Robert Wood Johnson Foundation & Institute for Healthcare Improvement. TCAB Communications Guidelines

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