MA STAAR Fall Learning Session Early Assessment of Post-Hospital Needs

1
MA STAAR Fall Learning SessionEarly Assessment
of Post-Hospital Needs
115-230PM Breakout Massachusetts General
Hospital and Sturdy Memorial
Hospital Patricia Rutherford, Kate Bones
2
(No Transcript)
3
IHIs Roadmap for Improving Transitions and
Reducing Avoidable Rehospitalizations
Improved Transitions and Coordination of
Care Reduction in Avoidable Rehospitalizations
or
Additional Costs for these Services
Patient and Family Engagement
Cross-Continuum Team Collaboration
Evidence-based Care in All Clinical Settings
Health Information Exchange and Shared Care Plans
4
Key Changes to Create an Ideal Transition Home

1. Perform an Enhanced Assessment of Post-Hospital
   Needs
2. Provide Effective Teaching and Facilitate
   Enhanced Learning
3. Ensure Post-Hospital Care Follow-up
4. Provide Real-Time Handover Communication

5
Perform an Enhanced Assessment of Post-Hospital
Needs

1. Involve the patient, family caregiver(s), and
   community provider(s) as full partners in
   completing a needs assessment of the patients
   home-going needs.
2. Reconcile medications upon admission.
3. Identify the patients initial risk of
   readmission.
4. Create a customized discharge plan based on the
   assessment.

6

• What is one new thing you learned today that you
  would like to test?