The Key To Successful Transition of Care – - PowerPoint Presentation

1. The Key To Successful Transition of Care – A TEAM APPROACH1Bridging the Information Gap Across the Continuum of Care

2. Danville Cross Setting WorkgroupGoal: Prevent skin breakdown or worsening of an existing pressure ulcer by getting the necessary skin/wound information about an individual to the next setting. This required a commitment of everyone involved to renew our focus on the patient at the center of the transition process, to understand what each setting needs to make the patient at high risk for pressure ulcers safer and prioritize opportunities identified. Lessons learned from first meeting:** Anytime someone will listen to your problems, PEOPLE WILL COME AND PARTICIPATE!!Initial Group: First Meeting: December 3, 20093 Nursing HomesDanville Regional Medical Center (Quality Director, Case Management, Emergency Room, Risk Management)VHQC Facilitator 2

3. 3Where do we begin? 1) Outlined the current process for skin assessment in each setting. 2) Identified specific problems 3) Identified resolutions and provided timelines for problem resolution.4) Needed every person who touched the patient to be involved so we invited additional people to join the team .WE NEEDED A TEAM APPROACH!!

4. Pressure UlcersProblems identified at time of/during transition. 1) Long wait times in the ER- immobile patients not turned/positioned 2) Poor communication between the Nursing homes and hospital 3) Delays in transportation causing possible skin breakdown due to lack of turning and positioning. 4) Some nursing homes had different admission processes/requirements. Solutions discussed honestly and realistically with assignments for follow up given to each member. Accountability for each person was mandatory!4

5. Hourly rounding in the Emergency Room on all patients. (This has been implemented hospital wide on all nursing units). Place all patients being admitted in a hospital bed if no rooms are available at time of admission. Nursing checks the patient immediately prior to transportation. If transportation is delayed, the agency will contact the nurse on the unit. Nursing Homes call the patients Case Manager or nurse to inform them if the resident has an ulcer. Ensure consistent documentation of High Risk and Pressure Ulcer stage/current treatment goes with the patient to each setting. 5Changes Implemented:

6. Biggest Problem in Our Process:Lack of consistent communication and tools. SBAR (Situation, Background, Assessment, Recommendation) Many tools evaluated by the team. Trial and Error. It’s OK to make mistakes!Don’t reinvent the wheel, look at what you are already using. EVERYONE follows the decision made by the majority.6Communication - The Key to Every Successful Team

7. Tools we decided to use:1) Phone call to Nursing Home to give them a verbal report. If no answer, send written standard report. Have a designated line to call for each nursing home and a contact person .2) For transportation issues/concerns, we decided to have a contact person at the hospital who would follow up concurrently on any issues. A transportation contact person was also assigned for the hospital to contact for any concerns/issues.3) The Director of Information Systems started a year long process of obtaining consent from corporate to give electronic access to all nursing homes. This was approved in October, 2011. This allows consistent, accurate patient information to all nursing home facilities to ensure continuity of care. Access to all of the patient’s information enables all providers to have all documentation needed to put the patient as the top priority. “Coming together is a beginning; keeping together is progress; working together is success." Henry Ford  7Communication Con’t

8. 1) Improving Discharge Disposition Codes- Nursing Homes to contact Case Management if the disposition code changes from stated code at time of discharge. Less than 1% error monthly.2) Do Not Resuscitate Forms – a copy of the DNR form for Virginia is accepted during transport (in case the original is not available).3) High volume of admissions causing delays in discharged patients leaving. Transportation agency added new shifts and trucks to meet the needs of the community.4) Education provided to all nursing units on how to complete the Physician Certification Forms as they arrange this on the weekends.5) Case Management to notify transportation agency when heavy discharges expected so they can rearrange staffing, call in additional staff when needed.6) Hospital Respiratory Therapy Department provided education to local Nursing Homes on nebulizer treatments, new trach care and providing competency check off for NH nurses. Other Improvements Made! 8

9. 7) Transportation agency purchased new ventilator due to cross setting discussions.8) Improvement in pain management for all patients by routinely providing pain medication prior to transportation pick up. 9) Forum for all settings to inform of changes, new services available. 10) Identified specific personnel in the nursing home, hospital, and transportation agency to call if any issues need immediate resolution. 11) Heart Failure Coordinator provided education to nursing homes on Congestive Heart Failure to assist with assessment and maintain stabilization of CHF patient. 12) Policy was written regarding controlled substances not stocked in EMS medication box for EMS Transport from DRMC. 13) Assistance in ensuring correct equipment is returned to the correct place (i.e. wheelchairs, O2, etc)9Improvements Con’t

10. Many Opportunities; Many ObstaclesAlbert Schweitzer“ At times our own light goes out and is rekindled by a spark from another person. Each of us has cause to think with deep gratitude of those who have lighted the flame within us.”10

11. Danville Regional Medical CenterRiverside Health and RehabGretna Health and Rehabilitation CenterPiney Forest Health and Rehabilitation CenterStratford Rehabilitation CenterRoman Eagle Memorial Home, Inc.Chatham Health and Rehabilitation CenterVans Med TechRegional One Transportation11Acknowledgments