Transitional Care Model.

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Transitional Care Model.
WRC SENIOR SERVICES’
The Journey
Implementing Transitional Care
Fran Roebuck Kuhns, President-CEO
Marge Clark, MSN, Director of Transitional Care, Nurse Navigator
Hope Martin, RN, Director of Nursing, McKinley Health Center
Dawn Jeannerat, MSN, AGACNP Candidate,
Rehab Manager, McKinley Health Center
Kelly Snell, RN, Director of Professional Services,
Home Care, Home Health, Hospice
WRC SENIOR SERVICES’
THREE OVERARCHING GOALS

BEST PLACE TO LIVE FOR THOSE WE SERVE

BEST PLACE TO WORK FOR OUR CARE PARTNERS

FINANCIALLY SOUND FOR OUR FUTURE
ENVIRONMENTAL INFLUENCES

Health Care Reform

Resources: Money, Material, People

Regulations & Corporate Compliance

Growing numbers of Elders & The Great Divide
GENERATIVE THINKING:
ROLE OF GOVERNANCE

Articulate Mission, Vision,
Values

Strategic Planning

Quality Oversight

Customer Satisfaction

Talent Development

Financial Stewardship
ROLE OF
LEADERSHIP/MANAGEMENT

Live Mission, Vision, Values

Execute Tactical Plans

Person First Culture Change

Data Dashboards

Scorecards & P4P

Pilot Studies & KPI
EVIDENCED BASED PRACTICE MODELS EVALUATION CRITERIA
TRANSITIONAL CARE MODELS
RUBRIC
EVALUATION CRITERIA

Scholarly Research

Authors Name:
__________________________

Person-First Approach

Transactional Care Model:
____________________________

Patient Engagement/Goal Setting

Evaluator Name:
____________________________

Collaboration

The Rubric with evaluation criteria is used
to objectively score (EBP) Transitional Care
Models related to key indicators

Assessment Methodology

Nurse Competencies

Role of the MDT/IDT

Rank each criteria according to Likert Scale:

1= Unacceptable (not a fit for WRC) 2…3…4…
5= Excellent (Fits with WRC’s goals)
PILOT STUDY FRAMEWORK
Key
Performance Indicators
A-R-A Triangle
Org Charts
Core Competencies/Nurse LEAD
Position Expectations
NURSE LEAD

Licensed Staff Training & Development Protocols
 Core Competencies for Effective Leadership
 Conflict Resolution
 Delegation
 Critical Thinking
 Communication
 Collaboration
 Coaching & Counseling
TRANSITIONAL CARE MODEL:
PILOT STUDY
KEY PERFORMANCE INDICATORS
 Hospital
 Patient
(30 day)Readmissions
Satisfaction
 Physician
 Nurse
 Care
Satisfaction
Engagement
Partner Retention
 Quality
Indicator Improvements
Transitional Care Model
Marge Clark, MSN,
Nurse Navigator
Transitional Care Model
Goals
1.) Promote Person First care & services
2.) Establish horizontal & vertical communication networks
3.) Promote care outcomes
4.) Reduce avoidable re-hospitalizations.
5.) Improve Chronic Care Management
6.) Promote effective & timely care transitions
Theoretical Basis
Theory of Care:
Dr. Jean Watson
 Scholarly Search
 Evidenced Based
Practice Models

THE STORY OF TED

THE RAGU MAN

90TH BIRTHDAY
Focused Discharge Planning

Open & ongoing communication
 SBARM

Interdisciplinary team

Person-First goals

Patient education


Krames Stay well
Recognizing barriers
Discharge Planning
CHRONIC CARE MANAGEMENT
TRANSITIONAL CARE
WRC In Home Solutions
Home Health, Home Care, Hospice
Kelly Snell DPS RN
Key Components
 Consumer
Satisfaction
 Core Competencies
of Team
 Identification of
Gaps
 Communication
Collaboration
 Integrated Care
Delivery
Chronic Care Management
An Influential Start …
1.
Identified PHA
Conference
2.
Economic
Development Grant
3.
Certified Trainers
4.
Required for all
Licensed Staff
Characteristics of Chronic
Care Management
 Patient
Centered
goal setting
 Self-Management
 Motivational
Interviewing
 Interdisciplinary
approach
Benefits of Chronic Care Management
 Decrease
hospitalizations
 Maintain least restrictive environment
 Promote patient satisfaction
 Improve quality outcomes
 Prevention of exacerbations
 Patient Directed Care
Data Dashboard
HOSPITALIZATIONS PER 60 DAY EPISODE
25
20
15
10
5
0
2013
2015
2016
2013
2015
2016
STATE/NATIONAL AVERAGES
Data Dashboard
IHS Quality Indicators
WALKING AND MOVING
TRANSFERING IN AND OUT OF BED
UNPLANNED EMERGENT CARE
0
10
2015
20
2013
30
40
STATE/NATIONAL AVERAGE
50
60
70
80
Data Dashboard
HOME HEALTH CASE WEIGHT
1.4
1.2
1
0.8
0.6
0.4
0.2
0
2013
2015
2016
2013
2015
2016
STATE AND NATIONAL AVG.
Financial Viability
Home Health Operating Revenue
Productivity
10
$1,600,000
$1,200,000
$800,000
5
$400,000
$0
0
FY 2012
FY 2013
FY 2014
FY 2015
Visits/day/
practitioner
FY 2012
FY 2013
FY 2014
FY 2015
CONTINUOUS QUALITY IMPROVEMENT
 Patient advocate
 ANA Scope of Practice
 Chapter 7 Medicare Law
 Identification of high risk patients
 Census building leading to growth
 Financially sound
 Resources for community and patients
 Advanced care planning
COMMUNICATION IS CRITICAL

Communication:
Vertical and horizontal

Open dialogue among team

Internal
Communication(vertical)

External
Communication(horizontal)

Ongoing communication
quality improvement
Skilled Nursing &
Transitional Care
Hope Martin, RN, Director of
Nursing, MHC
CLINICAL PATHWAYS

Top 6 Re-hospitalization
Risks
 CHF
 COPD
 Pneumonia
 UTI
 GI
Bleed
 Diabetes
Mellitus
PALLIATIVE CARE PATHWAY
 Advanced
Care Planning
 PALLIATIVE CARE PHILOSOPHY
Motivational Interviewing
POLST
Palliative Care
Ethics Committee
INFORMATION SYSTEMS
 EMR
Care
 Telemedicine
Plans
Pathways
Shared
patient
Information
Matrix
Discharge
Care Plan
 Patient
Monitoring
 Tele-Med
Administration
 Sims
Training
Data Dashboard
MHC REHOSPITALIZATIONS PER MONTH
16
14
12
10
8
6
4
2
0
2013
2015
2016
2013
2015
2016
Data Dashboard
QUALITY INDICATORS
60
50
40
30
20
10
0
UTIs
ANTIANXIETY/HYPNOTICS
STATE/NATIONAL AVG.
2013
FALLS
2015
Data Dashboard
CASE MIX INDEX
1.4
1.2
1
0.8
0.6
0.4
0.2
0
2013
2015
2016
2013
2015
2016
state Average
ROLE OF THE RN IN SKILLED NURSING

Raising the Bar

Investment in Care Partner Skill Development

Role of Discharge Educator

Role of Rehab Manager, Advance Practice Nursing
Building Collaborative
Relationships to
Transform Culture
Dawn Jeannerat, RN, MSN, AGACNP Candidate
ROLE OF REHAB MANAGER

Expert Practitioner

A Critical Thinker

An Educator

A Collaborator

A Patient Advocate
PERSON-FIRST
 Person
 Patient
 Real
First Choices
Goals
Conversations
 Multi-disciplinary
Team
Critical Thinking

Getting out of task mode


Getting LPNs and Care Aides to Think
Nursing Assessment

Back to basics to identify common problems

Stopping the problem before it even starts

Stop N Watch

Appropriately educating at all levels

Importance of Root Cause Analysis

5 WHYS

Identifies weaknesses

Guides on the spot education
Role of ADVANCED PRACTICE NURSE
Advanced
Assessment Skills
Physician
Relationships
Advanced
Care Planning
Staff
Education
Root
Cause Analysis
Quality
Building Collaborative Relationships to
Transform Culture
October 2014
March 2015
UTIs
UTIs
State Avg
Our Avg
National Avg
State Avg
Our Avg
National Avg
Building Physician Relationships

What can we offer in house?

Providing accurate assessment so providers can make informed decisions

Prepping & Physician Rounding

Building Trust through confirmed staff competence

Building Trust through staff retention

Building Trust through improved patient outcomes

Building Trust through improved patient satisfaction
WRC STAFF RETENTION
Chart Title
120
100
80
60
40
20
0
12 mth retention
2013
Overall retention
2015
16 Goal
St/Natl Averages
Establishing Credibility
Care
Partners
Nurses
Physicians
Acute Care Partners
WALKABOUT:
WRC’S TRANSITIONAL CARE
JOURNEY
Literature Search

Agency for Healthcare Research and Quality (AHRQ), http://www.ahrq.gov/

AMDA, Transitions of Care in the Long Term Care Continuum practice guideline www.amda.com/tools/clinical/TOCCPG/index.html

American Society of Medicine, American Medical Directors Association

Bradway CW, et al. (2012). A qualitative analysis of an advanced practice nursedirected transitional care model intervention. The Gerontologist, 52(3):394-407.

CAPS - Consumers Advancing Patient Safety – Toolkits www.patientsafety.org

Care Transitions Intervention http://www.caretransitions.org
Literature Search

Caregiver Action Network - Family Caregiving Resources, www.caregiveraction.org/

Coalition for Evidence-Based Policy at: evidencebasedprograms.org/WordPress/

Coleman EA, Boult C. Improving the quality of transitional care for persons with
complex care needs. J Am Geriatrician Soc. 2008;51:556-557

Department of Health and Human Services (DHHS) www.hhs.gov/, United States
agency for providing essential human services

Gawande Etul. Being mortal, Medicine and What Happens in the End. Henry Holt and
Company. 2014.

Goal Attainment Scale, www.betterevaluation.org/evaluationoptions/GoalAttainmentScales, a tool to measure outcomes of patient-centered goal
setting.

Guided Care http://www.guidedcare.org
Literature Search

Hibbard JH, Greene J. (2013). What the evidence shows about
patient activation: better health outcomes and care experiences;
fewer data on costs. Health Affairs, 32(2):207-214

Institute of Medicine. Knowing What Works in Health Care: A
Roadmap for the Nation. Washington, DC: National Academies Press;
2008.

My Med Schedule, www.mymedschedule.com/

National Patient Safety Goals
http://www.jointcommission.org/patientsafety/nationalpatientsafet
ygoals
Literature Search

National Quality Forum (NQF), Quality Connections: Care Coordination. (October
2010). NQF, Washington. Accessible at:
www.qualityforum.org/Publications/2010/10/Quality_Connections__Care_Coordin
ation.aspx

Naylor MD, Van Cleave, J. (2010). The Transitional Care Model for Older Adults. In:
A.I. Meleis (Ed.), Transitions Theory: Middle Range and Situation Specific Theories
in Research and Practice. New York: Springer. pp. 459‐465.

Naylor MD. A decade of transitional care research with vulnerable elders. J
Cardiovascular Nursing. 2000;14(3):1-14

NTOCC - National Transitions of Care Coalition – Provider & Consumer Tools,
www.ntocc.org

Project RED (Re-Engineered Discharge)
http://www.bu.edu/fammed/projectred/index.html

Rabidoux, Denise, et.al. Evangelical Homes of Michigan. Transitional Care Model.
Feb 2013.
Thank you!
Questions
Answers
Next
Practices

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