TIP OF THE WEEK
Transitional Care Coordination and the Acute Care Hospitalization Connection
Encouraging patients and their caregivers to take an active role during care transitions may reduce avoidable re-hospitalization rates, according to a study published in the Archives of Internal Medicine (September 25, 2006). [1]
The care transitions intervention study was built on four pillars or conceptual areas that include:
- Medication self-management
- Patient-centered record owned and maintained by the patient
- Timely follow-up with primary or specialty care
- A list of “red flags” that indicate worsening in condition and instructions on how to respond
These pillars were supported by two main interventions: a personal health record and a series of visits and phone calls by a transition coach.
WHAT CAN THE CLINICIAN DO TO SUPPORT TRANSITIONAL CARE COORDINATION?
Consider the following best practice interventions and processes:
- Fine-tune your agency’s best practice interventions and processes, and then follow them consistently.
- Collaboratively develop an emergency care plan with patients/caregivers that identifies who and when to call with changes in health status.
- Reconcile medications during transitions from hospital to home.
- Ensure that patients follow up with their physician appointments.
- Help patients prepare in advance for physician appointments by developing with them questions about their concerns.
- Utilize the Situation-Background-Assessment-Recommendation (SBAR) method to improve communication.
- Ask patients about their personal health record and encourage them to keep it up-to-date.
- Communicate effectively with other interdisciplinary team members to ensure smooth patient transitions from one discipline to the other.
RESOURCE SPOTLIGHT
Transitional Care Coordination Best Practice Improvement PackageThis is a comprehensive manual for home health agency leadership and staff to identify tools and processes to improve patient transitions from one healthcare setting to another. Interventions focus on the four pillars, or conceptual domains, of patient transition. The package includes tools and resources for patients and staff.
SBAR Package for Home Health Agencies
SBAR (Situation, Background, Assessment, and Recommendation) is a device that can be used to improve communication within the home health arena. The SBAR Home Health Package includes an SBAR tool, an SBAR tool for COPD, a flyer, a pocket card, phone stickers, references, sample scenarios, and more.
IN THE NEWS
TWO EFFORTS SPUR ELECTRONIC MEDICAL RECORDS SYSTEM
February 21, 2008 -- Cleveland Plain Dealer -- The Cleveland Clinic will ask thousands of its eCleveland Clinic MyChart patients to participate in a project with search-engine giant Google, which is looking to develop a secure electronic highway to transport patient health records. Across town at MetroHealth Medical Center, Kerry Weems, acting administrator at the Centers for Medicare & Medicaid Services, challenged more than 30 Northeast Ohio healthcare leaders to adopt electronic health record systems for small- and mid-sized physician practices. The systems would let physicians compile records in their offices and also make records accessible for use outside the office. Read more >>
MORE ELDERLY AMERICANS ARE LIVING WITH HEART FAILURE
February 25, 2008 -- JAMA -- The number of elderly individuals newly diagnosed with heart failure has declined during the past 10 years, but the number of those living with the condition has increased, according to a report in the February 25 issue of Archives of Internal Medicine, one of the JAMA/Archives journals. Read more >>
OHIO KEPRO EVENTS
COMING ATTRACTIONS
Cuyahoga Community College Spring ’08 Continuing Education Schedule for Gerontology Professionals
Quality Measurement: A Data-Driven Approach To Healthcare Improvement
A national QIO audio and/or Web conference
Wednesday, March 12, 2008, 12:00 to 1:30p.m. ET
Measuring and analyzing data is critical to improving healthcare processes and outcomes. This presentation is aimed at providing an overview of the most common measurement strategies in healthcare. The presenter will describe measures of variation, basic statistical methods (run charts and control charts), and the rationale and limitations for using various methods.
Presenter: Donna Daniel, PhD, Corporate Director for Quality Measurement and Improvement, Atlantic Health, New Jersey
The Tip of the Week Archive is available on the Ohio KePRO Web Site.
Clinically driven. Client focused. Value based.