Nothing Special   »   [go: up one dir, main page]
Scribd Logo
Upload

Welcome to Scribd!

  • 32 views

    Age Presentation

    Uploaded by

    Aamir Aziz
    This document outlines WRC Senior Services' implementation of a transitional care model. It discusses their three overarching goals of providing the best place to live and work and ensuring financial soundness. It then describes how they evaluated evidence-based transitional care models and selected one to pilot involving key stakeholders. The pilot aims to improve outcomes like reducing hospital readmissions through strategies like standardized assessments, care coordination, and chronic care management across care settings. Speakers then each provide more details on their roles in making the model a success through approaches like standardized training, clear communication, and data tracking of metrics.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd

    Age Presentation

    Uploaded by

    Aamir Aziz
    32 views49 pages
    This document outlines WRC Senior Services' implementation of a transitional care model. It discusses their three overarching goals of providing the best place to live and work and ensuring financial soundness. It then describes how they evaluated evidence-based transitional care models and selected one to pilot involving key stakeholders. The pilot aims to improve outcomes like reducing hospital readmissions through strategies like standardized assessments, care coordination, and chronic care management across care settings. Speakers then each provide more details on their roles in making the model a success through approaches like standardized training, clear communication, and data tracking of metrics.

    Original Description:

    Original Title

    Age presentation

    Copyright

    © © All Rights Reserved

    Available Formats

    PPTX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This document outlines WRC Senior Services' implementation of a transitional care model. It discusses their three overarching goals of providing the best place to live and work and ensuring financial soundness. It then describes how they evaluated evidence-based transitional care models and selected one to pilot involving key stakeholders. The pilot aims to improve outcomes like reducing hospital readmissions through strategies like standardized assessments, care coordination, and chronic care management across care settings. Speakers then each provide more details on their roles in making the model a success through approaches like standardized training, clear communication, and data tracking of metrics.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    32 views49 pages

    Age Presentation

    Uploaded by

    Aamir Aziz
    This document outlines WRC Senior Services' implementation of a transitional care model. It discusses their three overarching goals of providing the best place to live and work and ensuring financial soundness. It then describes how they evaluated evidence-based transitional care models and selected one to pilot involving key stakeholders. The pilot aims to improve outcomes like reducing hospital readmissions through strategies like standardized assessments, care coordination, and chronic care management across care settings. Speakers then each provide more details on their roles in making the model a success through approaches like standardized training, clear communication, and data tracking of metrics.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 49

    WRC SENIOR SERVICES’

    The Journey
    Implementing Transitional Care
    Fran Roebuck Kuhns, President-CEO
    Marge Clark, MSN, Director of Transitional Care, Nurse Navigator
    Hope Martin, RN, Director of Nursing, McKinley Health Center
    Dawn Jeannerat, MSN, AGACNP Candidate,
    Rehab Manager, McKinley Health Center
    Kelly Snell, RN, Director of Professional Services,
    Home Care, Home Health, Hospice
    WRC SENIOR SERVICES’
    THREE OVERARCHING GOALS
     BEST PLACE TO LIVE FOR THOSE WE SERVE

     BEST PLACE TO WORK FOR OUR CARE PARTNERS

     FINANCIALLY SOUND FOR OUR FUTURE


    ENVIRONMENTAL INFLUENCES
     Health Care Reform
     Resources: Money, Material, People
     Regulations & Corporate Compliance
     Growing numbers of Elders & The Great Divide
    GENERATIVE THINKING:

    ROLE OF
    ROLE OF GOVERNANCE
    LEADERSHIP/MANAGEMENT
     Articulate Mission, Vision,  Live Mission, Vision, Values
    Values  Execute Tactical Plans
     Strategic Planning  Person First Culture Change
     Quality Oversight  Data Dashboards
     Customer Satisfaction  Scorecards & P4P
     Talent Development  Pilot Studies & KPI
     Financial Stewardship
    EVIDENCED BASED PRACTICE MODELS EVALUATION CRITERIA
    TRANSITIONAL CARE MODELS

    RUBRIC EVALUATION CRITERIA


     Scholarly Research
     Authors Name:
    __________________________
     Person-First Approach
     Transactional Care Model:  Patient Engagement/Goal Setting
    ____________________________
     Collaboration
     Evaluator Name:
    ____________________________  Assessment Methodology
     The Rubric with evaluation criteria is used
    to objectively score (EBP) Transitional Care
     Nurse Competencies
    Models related to key indicators  Role of the MDT/IDT
     Rank each criteria according to Likert Scale:
     1= Unacceptable (not a fit for WRC) 2…3…
    4… 5= Excellent (Fits with WRC’s goals)
    PILOT STUDY FRAMEWORK

    Key Performance Indicators


    A-R-A Triangle
    Org Charts
    Core Competencies/Nurse LEAD
    Position Expectations
    NURSE LEAD

    Licensed Staff Training & Development Protocols


    Core Competencies for Effective Leadership
    Conflict Resolution
    Delegation
    Critical Thinking
    Communication
    Collaboration
    Coaching & Counseling
    TRANSITIONAL CARE MODEL:
    PILOT STUDY
    KEY PERFORMANCE INDICATORS

     Hospital (30 day)Readmissions


     Patient Satisfaction
     Physician Satisfaction
     Nurse Engagement
     Care Partner Retention
     Quality Indicator Improvements
    Transitional Care Model
    Marge Clark, MSN,
    Nurse Navigator
    Transitional Care Model
    Goals
    1.) Promote Person First care & services
    2.) Establish horizontal & vertical communication
    networks
    3.) Promote care outcomes
    4.) Reduce avoidable re-hospitalizations.
    5.) Improve Chronic Care Management
    6.) Promote effective & timely care transitions
    Theoretical Basis
    Theory of Care:
    Dr. Jean Watson
    Scholarly Search
    Evidenced Based
    Practice Models
    THE STORY OF TED
     THE RAGU MAN  90TH BIRTHDAY
    Focused Discharge Planning
     Open & ongoing communication
     SBARM

     Interdisciplinary team
     Person-First goals
     Patient education
     Krames Stay well
     Recognizing barriers
    Discharge Planning
    CHRONIC CARE MANAGEMENT
    TRANSITIONAL CARE

    WRC In Home Solutions


    Home Health, Home Care, Hospice
    Kelly Snell DPS RN
    Key Components
    Consumer Satisfaction
    Core Competencies of
    Team
    Identification of Gaps
    Communication
    Collaboration
    Integrated Care
    Delivery
    Chronic Care Management
    An Influential Start …
    1. Identified PHA
    Conference
    2. Economic
    Development Grant
    3. Certified Trainers
    4. Required for all
    Licensed Staff
    Characteristics of Chronic
    Care Management
    Patient Centered
    goal setting
    Self-Management
    Motivational
    Interviewing
    Interdisciplinary
    approach
    Benefits of Chronic Care Management
    Decrease hospitalizations
    Maintain least restrictive environment
    Promote patient satisfaction
    Improve quality outcomes
    Prevention of exacerbations
    Patient Directed Care
    Data Dashboard
    HOSPITALIZATIONS PER 60 DAY EPISODE
    25

    20

    15

    10

    0
    2013 2015 2016 STATE/NATIONAL AVERAGES

    HOSPITALIZATIONS PER 60 DAY EPISODE


    Data Dashboard
    IHS Quality Indicators

    WALKING AND MOVING

    TRANSFERING IN AND OUT OF BED

    UNPLANNED EMERGENT CARE

    0 10 20 30 40 50 60 70 80

    2015 2013 STATE/NATIONAL AVERAGE


    Data Dashboard
    HOME HEALTH CASE WEIGHT
    1.4

    1.2

    0.8

    0.6

    0.4

    0.2

    0
    2013 2015 2016 STATE AND NATIONAL AVG.

    CASE WEIGHT
    Financial Viability

    Home Health Operating Revenue


    10 Productivity
    $1,600,000

    $1,200,000

    5
    $800,000

    $400,000

    $0 0
    FY 2012 FY 2013 FY 2014 FY 2015 FY 2012 FY 2013 FY 2014 FY 2015
    Visits/day/
    practitioner
    CONTINUOUS QUALITY IMPROVEMENT
     Patient advocate
     ANA Scope of Practice
     Chapter 7 Medicare Law
     Identification of high risk patients
     Census building leading to growth
     Financially sound
     Resources for community and patients
     Advanced care planning
    COMMUNICATION IS CRITICAL
     Communication:
    Vertical and horizontal
     Open dialogue among team
     Internal
    Communication(vertical)
     External
    Communication(horizontal)
     Ongoing communication
    quality improvement
    Skilled Nursing &
    Transitional Care
    Hope Martin, RN, Director of
    Nursing, MHC
    CLINICAL PATHWAYS
     Top 6 Re-hospitalization
    Risks
     CHF

     COPD

     Pneumonia

     UTI

     GI Bleed
     Diabetes Mellitus
    PALLIATIVE CARE
    Advanced PATHWAY
    Care Planning
    PALLIATIVE CARE PHILOSOPHY
    Motivational Interviewing
    POLST
    Palliative Care
    Ethics Committee
    INFORMATION SYSTEMS
     EMR  Telemedicine
    Care Plans  Patient Monitoring
    Pathways  Tele-Med
    Shared patient Administration
    Information  Sims Training
    Matrix Discharge
    Care Plan
    Data Dashboard
    MHC REHOSPITALIZATIONS PER MONTH
    16

    14

    12

    10

    0
    2013 2015 2016

    REHOSPITALIZATIONS PER MONTH


    Data Dashboard
    QUALITY INDICATORS
    60

    50

    40

    30

    20

    10

    0
    UTIs ANTI-ANXIETY/ FALLS
    HYPNOTICS

    STATE/NATIONAL AVG. 2013 2015


    Data Dashboard
    CASE MIX INDEX
    1.4

    1.2

    0.8

    0.6

    0.4

    0.2

    0
    2013 2015 2016 state Average

    CASE MIX INDEX


    ROLE OF THE RN IN SKILLED NURSING

     Raising the Bar


     Investment in Care Partner Skill Development
     Role of Discharge Educator
     Role of Rehab Manager, Advance Practice Nursing
    Building Collaborative
    Relationships to
    Transform Culture
    Dawn Jeannerat, RN, MSN, AGACNP Candidate
    ROLE OF REHAB MANAGER

     Expert Practitioner
     A Critical Thinker
     An Educator
     A Collaborator
     A Patient Advocate
    PERSON-FIRST
     Person First Choices

     Patient Goals

     Real Conversations

     Multi-disciplinary Team
    Critical Thinking
     Getting out of task mode
     Getting LPNs and Care Aides to Think
     Nursing Assessment
     Back to basics to identify common problems
     Stopping the problem before it even starts
     Stop N Watch
     Appropriately educating at all levels
     Importance of Root Cause Analysis
     5 WHYS
     Identifies weaknesses
     Guides on the spot education
    Role of ADVANCED PRACTICE NURSE
    Advanced Assessment Skills
    Physician Relationships
    Advanced Care Planning
    Staff Education
    Root Cause Analysis
    Quality
    Building Collaborative Relationships to
    Transform Culture
    October 2014 March 2015
    UTIs UTIs

    State Avg Our Avg National Avg State Avg Our Avg National Avg
    Building Physician Relationships

     What can we offer in house?


     Providing accurate assessment so providers can make informed decisions
     Prepping & Physician Rounding
     Building Trust through confirmed staff competence
     Building Trust through staff retention
     Building Trust through improved patient outcomes
     Building Trust through improved patient satisfaction
    WRC STAFF RETENTION

    Chart Title
    120

    100

    80

    60

    40

    20

    0
    12 mth retention Overall retention

    2013 2015 16 Goal St/Natl Averages


    Establishing Credibility

    Care Partners
    Nurses
    Physicians
    Acute Care Partners
    WALKABOUT:
    WRC’S TRANSITIONAL CARE
    JOURNEY
    Literature Search

     Agency for Healthcare Research and Quality (AHRQ), http://www.ahrq.gov/


     AMDA, Transitions of Care in the Long Term Care Continuum practice guideline -
    www.amda.com/tools/clinical/TOCCPG/index.html
     American Society of Medicine, American Medical Directors Association
     Bradway CW, et al. (2012). A qualitative analysis of an advanced practice nurse-
    directed transitional care model intervention. The Gerontologist, 52(3):394-407.
     CAPS - Consumers Advancing Patient Safety – Toolkits www.patientsafety.org
     Care Transitions Intervention http://www.caretransitions.org
    Literature Search
     Caregiver Action Network - Family Caregiving Resources, www.caregiveraction.org/
     Coalition for Evidence-Based Policy at: evidencebasedprograms.org/WordPress/
     Coleman EA, Boult C. Improving the quality of transitional care for persons with
    complex care needs. J Am Geriatrician Soc. 2008;51:556-557
     Department of Health and Human Services (DHHS) www.hhs.gov/, United States
    agency for providing essential human services
     Gawande Etul. Being mortal, Medicine and What Happens in the End. Henry Holt and
    Company. 2014.
     Goal Attainment Scale,
    www.betterevaluation.org/evaluation-options/GoalAttainmentScales, a tool to
    measure outcomes of patient-centered goal setting.
     Guided Care http://www.guidedcare.org
    Literature Search

     Hibbard JH, Greene J. (2013). What the evidence shows about


    patient activation: better health outcomes and care experiences;
    fewer data on costs. Health Affairs, 32(2):207-214
     Institute of Medicine. Knowing What Works in Health Care: A
    Roadmap for the Nation. Washington, DC: National Academies Press;
    2008.
     My Med Schedule, www.mymedschedule.com/
     National Patient Safety Goals
    http://www.jointcommission.org/patientsafety/nationalpatientsafe
    tygoals
    Literature Search
     National Quality Forum (NQF), Quality Connections: Care Coordination. (October
    2010). NQF, Washington. Accessible at:
    www.qualityforum.org/Publications/2010/10/Quality_Connections__Care_Coordin
    ation.aspx

     Naylor MD, Van Cleave, J. (2010). The Transitional Care Model for Older Adults. In:
    A.I. Meleis (Ed.), Transitions Theory: Middle Range and Situation Specific Theories
    in Research and Practice. New York: Springer. pp. 459‐465.
     Naylor MD. A decade of transitional care research with vulnerable elders. J
    Cardiovascular Nursing. 2000;14(3):1-14
     NTOCC - National Transitions of Care Coalition – Provider & Consumer Tools,
    www.ntocc.org
     Project RED (Re-Engineered Discharge) http://
    www.bu.edu/fammed/projectred/index.html
     Rabidoux, Denise, et.al. Evangelical Homes of Michigan. Transitional Care Model.
    Feb 2013.
    Thank you!
    Questions
    Answers
    Next Practices

    You might also like