INTERACT II

1. INTERACT II Your hosts: Jody Rothe, MetaStar Stephanie Sobczak, WHA November 2012

2. Acknowledgements • Thank you to these organizations for sponsoring this webinar series: A special thank you to the Wisconsin Clinical Resource Center for serving as the home base for recorded webinars and materials related to the INTERACT II collaborative

3. INTERACT II July Overview & Case Review Tools August Communication Tools September Early Warning Tools October Change in Condition Tools November Resident Transfer Tools December Continuous Improvement Tools

4. Today’s Agenda • Review 30 day Action Items & data update • Discussion • Share experiences with Change in Condition Card and Care Path testing • Review key Resident Transfer tools – Transfer Checklist, Resident Transfer Form • Working with Hospitals on Transfer Tools • Implementing Transfer Tools • 30 day Action Items

5. Results from Feedback Tool • What INTERACT II tools have you implemented? SBAR 78% Stop and Watch 75% Change in Condition 43% Care Pathway 32% • Are you able to keep up with monthly data submission? Yes 57% No 43%

8. Results from Feedback Tool • What is most challenging about the INTERACT II program? Joining webinars. 23% Obtaining materials from websites 3% Submitted data 30% Convening a staff team 36% Completing monthly action items 50% • Have you had interaction with your local hospital about care transitions? Yes 63% No 43%

9. Discussion • Can anyone share what their agenda items were for discussion with hospitals or other care providing organizations?

10. Key Question about Transfers • How does everyone have the right information at the right time to do what is right for the patient in the right setting?

11. About Transfers – 2 issues 1) Relies on very good communication between sites of care: Nursing Home  Hospital  Nursing Home (The physician is the arrow in this diagram) 2) Relies on consistent processes in each of the sites: Problem Identification, Documentation, Notification protocol need to be addressed consistently.

12. Communication between sites • Standardized patient transfer forms? • Checklists for staff? • Key personnel contact lists? • Site capability assessment?

13. Consistent processes • Is there agreement on transfer criteria? • Is it possible to return patient to LTC from ER (without an inpatient admission)? • Expectations around the transfer process (i.e. patient transport)?

14. It’s not the people…it’s the process! Everyone in the care continuum is responsible for ensuring their processes in handling patient/resident transfer is the best it could possibly be. • Hospitals • Primary Care • Home Health • Nursing Home • Community Based Organizations Continuous Improvement is a necessity between and within all sites.

15. Who is responsible for the handoff?

16. INTERACT II Tools • Resident Transfer Form • Clinical Capability Inventory • Acute Transfer Checklist

17. Resident Transfer Tools

18. Resident Transfer Tools What does each facility really need? “Less is more” Want information that is vital, and easy to find. Can one tool be designed for all sites to use???

19. Bring everyone around the table Sit down with referral sources. Talk about transfer that do well – how can you do more of that? Share what your clinical capabilites are. (vents? I.V.s? PCA’s?) Collect information on what is needed. Review the process for transferring people and paperwork.

20. Key Decisions Will you use a template? OR Design your own? Who will be involved in testing the drafted transfer tool? How will the feedback from those tests occur? When will you know it is ready to adopt?

21. Guest speaker • Co-designing transfer tools

22. Clinical Capability Inventory example • Why would sharing your facilities capabilities be beneficial for your working relationship with the hospital? Hospitals know in advance if the patients needs are in line with your facilities capabilities. Prevents re-work of “false start” admissions! Clarifies expectations between staffs and physicians.

23. Clinical Capability Inventory

24. Resident Transfer Process It can be very helpful to diagram the transfer of patients and information from one site to another

25. A simple diagram can be made Care plan indicates hospital transfer SBAR – update resident status Call Med Direct.

26. Resident Transfer Tools

27. INTERACT II TransferChecklist This check list can be secured to outside of envelope which hold documents for the transfer.

28. Poll Questions Which of the following tools have you used in the past? (Check all that apply) • Facility capability tool • Resident transfer tool • Acute care transfer checklist

29. Discussion Have you co-designed any of these with other provider entities in your community? Are there any recommendations for testing these changes on a small scale before implementing?

30. Poll Answers Which of the following tools have you used in the past? (Check all that apply) • Facility capability tool • Resident transfer tool • Acute care transfer checklist

31. Action Items for this Month • Review the Resident Transfer Tools with Staff • Have volunteer staff test the Resident Transfer Tools through small tests • Evaluate the tests • Decide to adapt/adopt/abandon • Submit data A Feedback Tool will be send after December 5th to assess your progress on these tasks.

32. Thank you! See you next month Next month: Continuous Improvement Tools