Download Care Transitions Infrastructure - Massachusetts Coalition for the

Massachusetts
Patient and Family Advisory Councils
Series Call #5
Engaging PFACs in the Improvement
of
Care Transitions
September 17, 2010
www.macoalition.org
Patient and Family Advisory Councils
Coalition Goals
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Support hospitals in establishing PFACs
Support hospitals in moving from being “patient and
family focused” to providing “patient and family
centered care”
Support hospitals in engaging their PFACs on the work
to improve care transitions.
Ma Coalition for the Prevention of Medical Errors
Institute for Family Centered Care
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Patient and Family Advisory Councils
Audio Conference Series
Audio Conferences Offered to MA Hospitals
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Call #1 - July 21, 2009
Call #2 - September 18, 2009
Call #3 - March 9, 2010
Call #4 - June 15, 2010
Call #5 – September 17, 2010
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Patient and Family Advisory Councils
Care Transitions
Context
 Key Recommendation of State Strategic Plan on Transitions
includes:
o Patient and Family Engagement :Using PFACs to improve
care transitions
 Have an opportunity for Coalition and hospitals to work
with PFACs in developing the framework that will help
improve care transitions statewide.
o Looking for hospitals to ask for regular input on this topic
from PFAC members.
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Patient and Family Advisory Councils
Care Transitions
Today - Comment from your experience
o How could hospitals use PFAC to improve care transitions?
o Make it a regular meeting agenda item?
o Have your PFAC comment on the strategy, process, and materials?
o Have you engaged your PFAC(s) in the discussion of transitions?
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What went well?
What didn’t go well?
Do you have recommendations from your PFAC?
If you haven’t worked on this topic yet, would you be able to obtain member feedback at your next
PFAC meeting?
o How could Coalition support hospitals in improving Care Transitions?
o We’ll compile what we hear today and share what is possible for a framework.
Will incorporate what hospitals doing nationally.
o Other ideas?
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Patient and Family Advisory Councils
Care Transitions Team
The following health care organizations are participating in this effort
MA Coalition for the Prevention of Medical Errors
MA Department of Public Health
Massachusetts Hospital Association
BayState Medical Center
Berkshire Hospital
Cambridge Health Alliance
Cape Cod Hospital
Emerson Hospital
Faulkner Hospital
Jordan Hospital
Kindred Northeast Rehabilitation Hospital
Massachusetts Eye and Ear
MetroWest Medical Center
Mount Auburn Hospital
New England Rehabilitation Hospital
Northeast Health Systems
Radius Health
Shaughnessy Rehabilitation Hospital
Shriners Children’s Hospital
Shaughnessy Kaplan Rehabilitation Hospital
UMASS Memorial
Winchester Hospital
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What Is the Ideal Discharge?
• We asked families to describe the ideal discharge at a
Family Advisory Council meeting
– Forty members divided into five groups of 8 people,
mixture of families and staff
– Each group described the ideal discharge for a specific
scenario (e.g. short illness, extended illness, out-of-town
family, surgery with follow-up therapy, different family
structures)
– We looked for common themes and key differences
• Follow-up survey, using Survey Monkey
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Results - Themes
• Give information
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Clear and professional
Timely
Identify who to call
Accommodate out-of-town families
• Plan ahead
– Start discharge planning at admission, including
predictions of timing
– Arrange parent education before the day of discharge
• Be flexible
– Discharge needs may vary with age and independence
– Consider the logistics of care at home
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Results - Quantitative
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Results - Quantitative
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Results - Quantitative
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Results - Quantitative
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Then what?
• Results presented to the Patient Flow team
and to the Patient Care Committee
• Physicians responded as if our work was
rocket science!
• Results informed the Patient Flow Team as
they tested new discharge processes.
• In February the team reported no flow failures
for the very first time.
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New Process Features
• Nursing staff in each unit worked with the
pharmacy to develop process to provide
prescriptions in hand at discharge.
• New discharge model based on family input
– Daily goals posted in patient rooms
– Discharge process begins at admission
– Discharge predictions (8-12, 12-4, 4-8) posted in
patient rooms and in charts
– Discharge coordinators
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When do we get to go home?
Sample Handout
•Developed by the Family
Advisory Council
•Currently being tested by a
couple of inpatient units
10 Questions to ask your child’s health care team...
1. When do you think my child will be discharged?
2. What time of day will my child be discharged? Can we make requests?
3. What goals does my child need to meet in order to go home?
4. What should we expect once we leave the hospital?
5. What is an emergency and who should I call?
6. Have my prescriptions been called into the pharmacy I prefer?
7. Who will teach us about my child’s medications?
8. Who will teach us any new skills we will need to perform for our child when
we get home? And/or will my child need homecare?
9. When do we need to see the doctor and has the appointment been made?
10. What other questions do we have? Have they been all answered?
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Figure 1: Care Transitions Infrastructure
Figure 1: Care Transitions Infrastructure
P
U
B
L
I
C
COA
Senior Center
Faith-based Org
Home Health
Agencies
Health Plans
Insurers
Emergency
Department
LTAC or
Rehab Hospital
Acute
Hospital
Patient and
Family
SNF
Hospice
Retail
Pharmacy
ADRC
ASAP
EMS
LTC Medical
Home: NH, AL
MH, DDS
Outpatient
Rehab
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H
E
A
L
T
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Patient and Family Advisory Councils
Next Steps
 Engaging Patients and Families in Improving Transition of Care:
o Local work of hospital to continue with PFAC Members engaged in the
discussion of improving both Care Transitions and hospital discharges.
o Looking for hospitals to ask for regular input on this topic from PFAC
members.
o Obtain support from hospitals to have Transitions be an on-going PFAC meeting
agenda item.
o Have your PFAC comment on the strategy, process, and materials.
o MA Coalition will continue to support shared local learning among MA
hospitals working with their PFACs on this topic
 Other Ideas??
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Massachusetts
Patient and Family Advisory Councils
Questions and/or Feedback?
Effie Pappas Brickman
Director, Patient and Family Advisory Councils
[email protected]
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