Transitions of Care

1. Transitions of Care Metro Health PHO

2. Preparing for Transitions of Care In May 2010, the Metro Health PHO held a 3 day LEAN event, which included multiple ambulatory practices, Metro Health Hospitals nursing units, pharmacy, hospitalists and key senior leaders in the organization

3. 7 Key Areas for Improvement During our three (3) day LEAN event, we used the BOOST methodology to look at the discharge process from the hospital to outpatient centers. During the event we identify seven keys areas for improvement:

4. 7 Key Areas for Improvement 1. Follow-up appointments for all CHF patients are scheduled with their Primary Care Physician (PCP) prior to discharge so the appointment occurs within 7 days of discharge

6. 7 Key Areas for Improvement All CHF patients need to have an initial home health care evaluation to ensure the appropriate follow-up and standards of care occur

7. 7 Key Areas for Improvement 3. All patient Discharge Instructions will contain all core measure data elements and all providers of care must enter patient discharge readiness into EHR prior to the discharge Instructions being printed

11. 7 Key Areas for Improvement 4. For patients in Skilled Nursing Facilities clear expectations of the CHF pathway are communicated to ensure compliance with standards of care

12. 7 Key Areas for Improvement 5. Provide accurate, easy, and concise discharge summaries to providers throughout the continuum of care

15. 7 Key Areas for Improvement Provide consistent case management from admission through discharge on CHF unit.

16. 7 Key Areas for Improvement cont. 7. Development of a multidisciplinary care team to ensure better communication, continuity of care and decrease of readmissions

17. Plans Moving Forward • Expand Transitions of Care to AMI and Pneumonia Patients • Educational tools have been developed • Staff training will be complete by 11/30/2011

18. Plans Moving Forward • Multi-disciplinary Rounds -Initially started to review case with extended ALOS (Average Length of Stay)

19. Plans Moving Forward • High Risk Assessment Tool • Developed in EPIC • Initial tool included 5 out of the 8 P’s: • Psychological • Pharmacy • Patient Support • Principal Diagnosis • Prior Hospitalizations

22. Questions??