MA STAAR Fall Learning Session Ensuring Post-Hospital Care Follow-up

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MA STAAR Fall Learning Session Ensuring
Post-Hospital Care Follow-up

• 245-400PM Breakout
• St. Annes Hospital, MetroWest Medical Center
• Peg Bradke and Kate Bones

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Creating an Ideal Transition Home
Perform Enhanced Admission Assessment of Post-Hospital Needs
II. Provide Effective Teaching and Facilitate Enhanced Learning
III. Ensure Post-Hospital Care Follow-Up Reassess the patients medical and social risk for readmission. Prior to discharge Schedule timely follow-up care and Initiate clinical and social services summarized from the assessment of post-hospital needs.
Provide Real-Time Handover Communication Give patient and family members a patient-friendly post-hospital care plan which includes a clear medication list. Provide customized, real-time critical information to next clinical care provider(s). For high-risk patients, a clinician calls the individual(s) listed as the patients next clinical care provider(s) to discuss the patients status and plan of care.
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How do we effectively and efficiently act on our
assessment of post-discharge needs and
collaborate with patients, their families, and
the community (healthcare and support systems) to
transition.
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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
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Requested Coordinating Activities and
Communications

• What information does the receiver need from
  hospitals
• What information the community providers can
  provide to the hospitals

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Potential Next Steps

• Practice(s) and/or their representatives become
  part of the hospitals STAAR CCT.
• Hospital STAAR CCT chair appoint a contact who
  will work with the practices or community
  provider and report back to the CCT regularly.
• At a CCT meeting (including the practices and/or
  their representatives) the CCT reviews a patient
  case where lack of coordination between the
  hospital and practice had an impact on patient
  care.
• Based on the patient case, the practice(s) and/or
  their representatives and the hospital CCT select
  2-3 areas to begin testing how to best coordinate
  activities and communications.
• Community providers and the hospital contact
  develop a work plan for learning from testing and
  addressing all the agreed upon change areas.

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Discussion

• Who is working with practices and clinics now?
• How are you cooperating to reduce risk for
  readmission?

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Social Risk Assessment

• Besides Meals on Wheels, what other social
  service and community resources do you refer your
  patients to?
• Does anyone have a useful check list for
  identifying social risks (lives alone, little
  involvement of others in care, anxiety and/or
  depression, quality of life, and functional
  status, along with socioeconomic status)?

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Social Support

• Social support is broadly defined as the
  existence or availability of people on whom one
  can rely people who let one know that they are
  cared about, valued, and loved. Lack of social
  support is associated with increased morbidity
  and mortality in patients with ischemic heart
  disease." (Vaglio, Conrad,  et al Testing the
  performance of the ENRICHD Social Support
  Instrument.  Health Qual Life Outcomes. 2004 2
  24.) 

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ENRICHD Social Support Instrument 

• "The results also provide conceptual insight into
  the nature of social support. The majority of
  questions on the ESSI consider general feelings
  about being loved and valued rather than
  instrumental types of support. This supports the
  theory that social support is not a tally of
  actual supportive "services" rendered, but rather
  a patient's belief that others care about them
  and are available if needed."

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Health Literacy, Medication Adherence and Social
Support

• "having a trusted confidant was the only type of
  social support associated with better medication
  adherence for limited-literacy patients
• (Johnson, Jacobson et al.  Does social support
  help limited-literacy patients with medication
  adherence? A mixed methods study of patients in
  the Pharmacy Intervention for Limited Literacy
  (PILL) Study.)

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Discussion

• How might we expand social support beyond the
  technical to include assessing for someone who
  cares about me?
• How might this help us? Help patients?

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