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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 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 2 Patient and Family Advisory Councils Audio Conference Series Audio Conferences Offered to MA Hospitals 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 3 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. 4 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? 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? 5 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 6 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 7 Results - Themes • Give information – – – – 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 8 Results - Quantitative 9 Results - Quantitative 10 Results - Quantitative 11 Results - Quantitative 12 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. 13 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 14 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? 15 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 16 H E A L T H 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?? 17 Massachusetts Patient and Family Advisory Councils Questions and/or Feedback? Effie Pappas Brickman Director, Patient and Family Advisory Councils [email protected] 18