MA STAAR Fall Learning Session Real-Time Handover Communication

1. MA STAAR Fall Learning SessionReal-Time Handover Communication 2:45-4:00PM Breakout Cape Cod Hospital, Hallmark Health System Gail Nielsen, Marian Bihrle-Johnson

3. IHI’s 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 • Perform an Enhanced Assessment of Post-Hospital Needs • Provide Effective Teaching and Facilitate Enhanced Learning • Ensure Post-Hospital Care Follow-up • Provide Real-Time Handover Communication

5. Provide Real-Time Handover Communication • Give patient and family members a patient-friendly post-hospital care plan that includes a clear medication list. • Provide customized, real-time critical information to the next clinical care provider(s). • For high-risk patients, a clinician calls the individual(s) listed as the patient’s next clinical care provider(s) to discuss the patient’s status and plan of care.

6. Identify Opportunities • Observe patients and staff during discharge handovers • Seek information on usefulness of handover information • Exchange visits with community partners: “Go See” and observe together • Review cases of readmitted patients with community providers • Interview readmitted patients and their families: what didn’t work well?

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