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Download Expand Specialty Care Project Identification: 094108002.1.2
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Expand Specialty Care Project Identification: 094108002.1.2 Mother Frances Hospital Intervention Development of Heart Failure (CHF Clinic) • Hospital based APP and RN provide education for patients with CHF • Patients are scheduled to return for follow up visit in Heart Failure clinic within 7‐10 days post discharge Goals • Reduce readmissions and LOS • Provide continued education and resources post discharge Pulmonary Clinic (Opened March 2013) • Easy Access • Clinical Coordinator • Timely, protocol driven testing & procedures Lung Nodule Clinic • Clinical pathways based on lung nodule size • Patients identified through imaging reports • Education of PCP’s by Pulmonologist & Nurse Navigator • Follow up for high risk patients more stringent • Multi‐Specialty Visits Goals • Early detection of Lung Cancer • Timely diagnosis • Collaborative decision making • Easy Access Heart Valve Clinic (Opened June 2014) • Patients identified with 1 of 3 sets of criteria for potential heart valve problems are referred to HVC • Data mining of data and Echo alerts for patients with criteria • Multi‐Specialty visits and collaboration to develop a plan of treatment • Tests review by physicians prior to visits • If surgery required, patient scheduled prior to leaving the clinic Goal • Increase lifespan of patients with Aortic Stenosis Accomplishments Team Approach • Multi‐Specialty Visits • Cardiothoracic Surgeons/Cardiologists • Cardiothoracic Surgeons/Pulmonologists • Nurse Navigators working with physicians • Improved access • Timely diagnostic testing Defined Protocols • Clinical pathways based on lung nodule size • Echo Alert Protocols • Data Mining of data Exceeded Expectations the first year of Heart Valve Clinic – 137 successful surgeries performed Worked with clinic staff, radiology, oncology, cardiothoracic surgery, pulmonology, bronch lab and OR to provide coordinated testing and access for success. Anticipated Patient Impact Heart Failure Clinic follow up provides • Continued patient education • A place to get help or answers without going to the Emergency Department Pulmonary Lung Nodule Clinic • Early detection of lung cancer saves lives • Public education of smoking cessation • Education of statistics for lung cancer on our region Heart Valve Clinic • Valve replacement surgery will improve the lifespan of the patient (Survival after onset of symptoms of Aortic Stenosis is 50% at 2 years) • Improved lifestyle For more information, contact: Mary Elizabeth Jackson Trinity Mother Frances Hospitals and Clinics Email: [email protected] Website: www.tmfhc.org Phone: (903) 531‐4788 Challenges / Lessons Learned Finding and Hiring of Essential Staff • Nurse Navigator • Physician Assistant Coordination of the Correct mix of providers on multi‐disciplinary teams • Adjustments were made to the team Importance of communication • Between providers and departments in caring for patients • Budgets and staffing to cover additional volumes Implement/Expand Care Transitions Program Project Identification: 094108002.2.3 Mother Frances Hospital Intervention Goals ●Provide smooth transition of care from hospital to home ●Improve patient quality of life by encouraging lifestyle changes and compliance ●Reduce healthcare costs by decreasing readmissions/ER visits Identify Patient Care Barriers ●Compliance factors ●Financial, psychological Impact ●Family/home support ●Assess physical, cognitive and psychosocial function/limitations Utilize Post‐Hospital CHF Clinic ●Timely post hospital reassessment Utilize Intensive Medical Home Clinic ●Referrals for non‐funded and Medicaid patients without Primary Care Provider Pro‐Active Patient Contacts ●Nurse Navigator follow up contacts ●Patient initiated contacts to Nurse Navigator ●Encourage family involvement in all aspects of care Utilization of Home Healthcare Agencies ●Home CHF monitoring protocols ●Vital signs telemonitoring Patient Education ●Condition patients to be “active participants” in their care ●Diet , medication, and activity counseling ●Teach how to manage dynamic and symptom changes Utilize ConnectCare (EPIC) EMR ●Enroll and encourage use of MyChart ●Performance measures ●Exam room: Access to audio/visual educational tools‐ in development Accomplishments Identification of CHF Patients/Target Population Team Approach ●Active participation by Cardiologists, Hospitalists ●Utilization of specialized staff ●Heart Failure Nurse Navigator 10/2013 ●Physician Assistant 6/2014 Proactive Protocols ●Cardiac observation unit and ED ●Improved collaboration among multi‐disciplined providers, staff, and departments. ●Implemented referrals to Phase II Cardiac Rehab Paced to meet target enrollment with 12% Medicaid and 8% non‐funded mix despite high Medicare population Readmission Impact of 2% related to Heart Failure and 16.33% related to all causes Anticipated Patient Impact Challenges / Lessons Learned Positive Lifestyle Changes, Adjustments, and Attitudes which Improve Patient Quality of Life Finding Medicaid/Non‐funded Patients ●Medicare dominated patient population Favorable Feedback ●Increase in smoking cessation ●Improved dietary and activity habits ●Closer self‐monitoring of signs and symptoms, functional dynamics, and vitals signs Developing and Implementing Effective Protocols Improved Patient Compliance ●Increased utilization of generic medications and drug samples and pharmaceutical assistance programs for the unfunded ●Increased awareness and utilization of available community resources Better Follow‐up Post Hospital Discharge ●Follow‐up appointment made before discharge ●Increased communication with reduced readmissions and ED visits Patient establishes healthy Long Term Heart Failure care For more information, contact: Mary Elizabeth Jackson Trinity Mother Frances Hospitals and Clinics Email: [email protected] Website: www.tmfhc.org Phone: (903) 531‐4788 Identifying Risk Assessment Tool Finding and Hiring of Essential Staff ●Nurse Navigator 10/2013 ●Physician Assistant 6/2014 Patients Lost to Rehab, Skilled Nursing Facilities, and Nursing Home Facilities ●CHF medication and care plan not adhered to ●No status or feedback from facilities when patient develops exacerbating symptoms or patient discharged Identification of CHF Inpatients ●Census reviewed on a daily basis TeleNICU Project Identification: 094108002.3.4 Felicia Adams, MS, RNC‐OB, NE‐BC Intervention The neonate is the most fragile of patients, and requires highly specialized physicians, nurses, staff and equipment to care for them safely and effectively. In September of 2013 Trinity Mother Frances in Tyler, TX. and Children’s Medical Center Dallas, began a TeleNICU program where a cross functional team from both entities assisted in reducing unnecessary transfers . Trinity Mother Frances (TMF) has a Level III Neonatal Intensive Care Unit (NICU) staffed 24/7 by Trinity Clinic board‐certified neonatologists and Children’s Medical Center Dallas (CMCD) has a Level IV NICU staffed by UT Southwestern (UTSW)board‐certified neonatologists. This collaboration was designed to allow the neonate to remain in their home NICU and receive Level IV care remotely when possible. Accomplishments The project has resulted in: • The reduction of unnecessary transfers From September 2013‐May 2014 twenty TeleNICU consults have been completed resulting in 6 neonates remaining in the Tyler level III NICU, while 14 were deemed in need of the Level IV care and transferred to Dallas. • Enhanced family centered care by involving the families in the consult 100% of patients verbalized appreciation for being included in the consult • Standardization of neonatal care through shared protocols and best practice • Developing quality measures on patient outcomes • Developing a family satisfaction tool • Providing enhanced access to cardiac echo processes for pediatric patients • Anticipation of exceeding expected utilization of all combined telemedicine tools • Improved reporting and time processing for results of telemedicine process for pediatricians • Enhanced communication through better exchange of information between local pediatricians and specialists Anticipated Patient Impact We anticipate adding more specialties to our Telemedicine program including: • TeleGenitics • Pediatric TelePsychiatry • TeleFetal • TeleMFM • TeleED • TMF as a “hub” for smaller communities Challenges to expanding the specialties have largely been related to contracts between the three entities of TMF, CMCD an UTSW. Movement is being made and a contract is anticipated soon. For more information, contact: Mary Elizabeth Jackson Trinity Mother Frances Hospitals and Clinics Email: [email protected] Website: www.tmfhc.org Phone: (903) 531‐4788 Raise the Floor There has also been collaboration with CMCD to educate others on the success of the TeleNICU program ,including Representative Lois Kolkhorst, who visited TMF to witness a TeleNICU consultation in progress. Dr. Eugene Toy, Chairman of the Perinatal Advisory Council, also visited TMF to observe the TeleNICU system and its capabilities. In tandem with the TeleNICU project, CMCD began a TeleSchool program in local Dallas public schools. This has allowed children of parents in a lower socioeconomical class to have a pediatrician “see” the patient without the parents missing work. A program like this could be replicated in the Tyler community.
