Integra(ng Pa(ents & Families as Advisors into our Care Transi(ons Work

Transcription

1 Integra(ng Pa(ents & Families as Advisors into our Care Transi(ons Work Alice Gunderson, BS Lead Pa(ent Family Advisor Mary Lynne Knighten, DNP, RN, PN, NEA- BC CNO/VP, Pa(ent Care Services St. Francis Medical Center February 13, 2015

2 Ed & Alice s Story IPFCC website, 2010 Conver'ng a pa'ent or family member with a story into a Pa'ent Family Advisor with a catalogue of experiences from which we can learn.

3 Partnering with Pa(ents and Families Where do you find us? Ø The easy way: Front end with lip service and back slaps. Ø The hard way: Difficult but rewarding Ø Mixture of both: Reflect the Community voice What does the PFA bring to the partnership? Ø Fear Ø History Ø Passion Ø Change Ø Perspec(ve What does the PFA seek? Ø Seat and voice at the table Ø Informa(on and knowledge Ø Resolu(on, progress and change

4 Engaging Pa(ents & Families as Partners and Advisors Pa'ent and Family Advisors are recruited by The Pa'ent Advocacy Department based on: Criteria: Ø Must be a pa(ent or family member of a pa(ent Ø Ability to be construc(ve (arise from a complaint) Ø Ability to match personal mission with hospital mission to improve care delivery and organiza(onal performance Ø Match passion and calling with PFA role and contribu(on Important considera(ons: Ø Time for pa(ents/families to process their experiences is significant; can t skip. Ø Pa(ents and families are not naturally advisors or educators; need significant instruc(on, coaching, and support in order for their stories to be teachable.

5 Ø PFA engagement in preven'ng readmissions? Ø Re- admissions begin on admission Alice s Story Discharge Begins on Admission! Ø Reflec'ons on Serving as an Advisor

6 Efforts to Reduce Re- Admissions & Engage Pa(ents as Partners and Advisors Ø Reducing Re- admissions Team Ø Interprofessional membership (MDs, front- line associates, PFA, Nursing, SW, Case Management, Educa(on) Ø Collabora(ves (ARC, BOOST, etc) Ø Transi(ons Models Ø Nurse Leader- led Care Coordina(on Rounds Ø Work Products: Ø LACE tool Ø CHF Pa(ent- Family Educa(on designed by Telemetry RNs and PFAs Ø Teach- Back Ø Spanish- English Discharge Instruc(ons co- designed with PFAs) Ø Pa(ent Guide (Spanish- English)

7 Bridging the Partnership Gap Ø Dissemina(on of Informa(on Ø Board educa(on (PFA on QPS) Ø Film screening of Escape Fire Ø Pa(ent & Family Centered Leadership Chapter in New Leadership for Today s Health Care Professionals Ø Pa(ent/Family Educa(on

8 Efforts to Reduce Re- Admissions & Engage Pa(ents as Partners and Advisors Integrated Care Support Across the Con(nuum (Unihealth grant funded) Ø Shig from loca(on- bound care to integrated pa(ent centered care support across the care con(nuum wherever the pa(ent is located Ø To help achieve the Ins(tute for Healthcare Improvement Triple Aim of Improved Quality, Pa(ent/ Family Experience and Cost Savings Ø Develop an integrated framework for assessing all pa(ents using predic(ve triggers to improve popula(on health management, improve pa(ent care, while lowering costs Ø Iden(fy and priori(ze appropriate follow- up care and triage the appropriate resource for follow up (NP, SW, MD) across a con(nuum of care sehngs (ER, hospital, home, SNF, residen(al care facility) Ø Work Products Ø Checklist for safely transi(oning a pa(ent back into the community Ø Medically appropriate POLST Ø Advanced direc(ve, Ø Three levels of care planning, 24/7 response plan and pa(ent ac(va(on plan to enable the pa(ent to recognize and manage their declining health symptoms to avoid calling 911 Ø Follow- up phone calls SFMC not an outlier with readmission to same No VBP penal'es 30- day readmit to other hospital opportunity (PEPPER)

9 Shiging from hospital- based care to pa/ent- centered integrated care support across a con(nuum of sehngs Integrated Care Support Program Naylor s Transi(onal Care Nurse Model Coleman s Care Transi(ons Interven(on Model Hospital Admission Discharge Care support for 4 weeks Using Advanced Prac/ce Nurses Hospital Discharge Care support for 30 days Using Social Workers Combine across 2 evidence- based models Our Integrated Care Support Model Iden(fy (using triggers) and screen target pa'ents ER Hospital Home SNF/RCF Assess pa(ent and develop individual care plan Care support for days Using MDs, Nurse Prac//oner and Social Workers

10 Efforts to Reduce Re- Admissions & Engage Pa(ents as Partners and Advisors Ø Integrated Care Support Across the Con(nuum (Unihealth grant funded)

11 Efforts to Reduce Re- Admissions & Engage Pa(ents as Partners and Advisors Lessons Learned: Ø Major source of re- admission based on pa(ent- driven demand for inappropriate/fu(le care is unrealis(c expecta(ons, caused in part by providers who have unrealis(c expecta(ons themselves or have a hard (me giving bad news. Ø POLST is a key tool for facilita(ng pa(ent wishes and planning for medically appropriate care, but is rela(vely unknown to the medical community. Ø Major difference between 24/7 nurse phone support vs 24/7 home visit response capability. Most home health and pallia(ve care agencies do not have the ability to send a nurse to a pa(ent s home ager hours and customarily advises their pa(ent to call 911. Ø Pa(ents welcome the declining health state discussion so they can plan ahead and be prepared for their eventual disease progression. Pa'ents need us to facilitate a discussion with family members to express the desires of their heart instead of leaving the burden of decision to family members or to chance. Ø The support provided by the ICS team works truly across a con(nuum of care sehngs, by establishing strong channels of communica(on with all providers, facilitate every aspect of the program from pa(ent iden(fica(on to care planning and care plan ac(va(on. Ø Unmanaged pain is a leading cause for calling 911, especially in the middle of the night when the PCP cannot be reached. Ø Steep drop- off seen in hospital costs for ICS pa(ents before (average $107K) vs. ($20K) ager they join the program

12 Ques'ons? Alice Mary Lynne