Clinical Strategies To Improve Patient Outcomes

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Clinical Strategies To Improve Patient Outcomes

• Care Transitions Between Health Care Providers
• Christine Stegel RN, MS, CPHQ
• Performance Improvement Coordinator
• Carol Ann Thomas RN, MS, CPHQ, COS-C
• Manager, Patient Safety and Quality Improvement
• St. Peters Home Care

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Objectives

• Define care transition
• Describe two evidence-based models for patient
  care transition
• Discuss one agencys experience in improving
  communication between the hospital and the home
  health agency

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Definition

• Care transitions are patient transfers from one
  care setting to another
• Transitional care includes all the services
  required to ensure the coordination and
  continuity of health care as the patient moves
  between one health care service provider to
  another

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Care Transition - Discharge Planning

• Referrals are received by fax or by telephone
• Discharge Liaisons
• HIPAA

5
Care Transition - Gaps

• Communication gaps
• - Physician
• - Referral process
• Patient self-management
• Care coordination
• Medication

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Care Transitions

• Two evidence-based care transition models
• Dr. Eric Colemans Transition Coach
• Dr. Mary Naylors use of an Advance Practice Nurse

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Care Transition Model- Dr. Eric Coleman

• Patient self-management
• - Medications
• - Know of signs of worsening condition
• Personal Health Record
• Primary Care Physician follow-up
• Transition Coach

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Care Transition Model- Dr. Eric Coleman

• Patient Self-Management
• Knowledge of medication actions, side effects,
  and interactions
• Medication management method
• Medication reconciliation when patient returns
  home
• Knowledge of signs of worsening condition

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Care Transition Model - Coleman

• Personal Health Record
• Demographic information including Primary Care
  Physician caregiver contact information
• Medical history
• Medication list allergies
• Checklist of activities that are needed prior to
  discharge
• Area for patients health care questions

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Transition Model - Coleman

• Transition Coach
• Facilitates interdisciplinary collaboration
• Ensures continuity of care
• Supports patient self-management activities
• Encourages the patient to take a more active role
  in their disease management and care decisions

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Transition Model - Coleman

• Care Transitions Measure measures the extent
  patients are being prepared to participate in
  post hospital self-care activities
• Source www.caretransitions.org

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Care Transition Model- Dr. Mary Naylor

• Advance Practice Nurse
• Identification of high-risk factors
• Multiple chronic conditions
• Evidence of depression or cognitive impairment
• Patient rates their health as poor
• Concerns with social supports
• History of re-hospitalizations

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Transition Model - Naylor

• Early identification of problems
• Collaborations with all care providers
• Continuity of care
• Utilizes frontloading of visits with telephone
  calls
• APNs are expected to use their clinical judgment

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Transition Model - Naylor

• Strategies
• Face to face interaction with the Physician while
  in hospital and then at first follow-up visit
  ability to develop a relationship/trust
• Medication reconciliation
• Early symptom management

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Summary Similarities Between the Two Models

• Used with patients who are complex/fragile
• Continuity of care between settings
• Interdisciplinary collaboration
• Medication reconciliation
• Regular timed follow-up post hospitalization