October 30, The Transitional Care Experience

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1 October 30, 2013 The Transitional Care Experience

2 The Transitional Care Experience Beth Ann Swan, PhD, CRNP, FAAN Dean and Professor Jefferson School of Nursing

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11 Who Do I Know in Chicago? The Professional Network Primary Contacts Sheila Haas Regina Phillips Kathy Krone Secondary Fran Vlasses, Loyola Michelle Janney, CNO Carol Payson Alan, Nurse Manager Anna McKee, JC Rita Axelrod s son, NICU attending Tertiary Former students from Loyola who knew Ida Androwich Current Loyola students: Elizabeth, Eric s nurse was a Loyola grad; Alan

12 Acute Care Hospitalization

13 Acute Care Hospitalization: Registered Nurses Elizabeth Wendy RiAnn Rachel and 2 nursing students Stacey Brightly Kate Maria Shelle Jackie

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15 Micro and Macro Transitions Neuro ICU Neuro Step Down Unit General Unit Acute Care Hospitalization Acute Inpatient Rehabilitation

16 Inpatient Rehabilitation: Registered Nurses

17 Macro Transitions Acute Care Hospitalization Acute Inpatient Rehabilitation Home

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19 Discharge to Home Handed a 10-page Rehabilitation Discharge Instructions Report Report listed need to schedule five appointments including: Rehab Physician within 3 weeks Neurologist within 2 weeks Vascular/Antithrombotic Service within 2 weeks Primary Care Provider within 2 weeks Physical Therapy as soon as possible

20 Discharge to Home Required to have blood draws for INR, first blood draw the next day Given seven prescriptions along with 29-pages of printed information Handed 5-pages of instructions for home safety Handed 6-pages of addresses for Outpatient Rehab facilities Handed a hand-written list of four community stroke support groups 55 pages of discharge instructions

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22 Discharge to Home Three prescriptions were filled before leaving the hospital Arrived home at 1PM Received telephone call at 4:45PM that Eric s lab values were not checked before leaving hospital and now he requires different dosages of the two of the three prescriptions

23 Transition to Home: Day #1

24 Sampling of Charges Bill for 911 for transport from O Hare International to Community Hospital = $1,149 Community Hospital = $23,312 (less than 24 hours) Bill for ambulance transfer from Community Hospital to Northwestern Memorial = $2,130 Physician Charges to Read Imaging = $2,117 Physician Charges one service = $1,380 Hospital Services = $77,689 including room and board ($33,750); pharmacy ($1,306); radiology ($14,719); med-surg-anesth supplies $85.00; laboratory ($20,988); rehab ($3,689); cardiology ($3,152)

25 Transition to Home: Day #2

26 Coordinating Care and Managing Transitions APPOINTMENT PRESCRIBED NEXT AVAILABLE SCHEDULED Rehab Physician 3 weeks or June 7 June 9, 2011 June 9, 2011 Neurologist 2 weeks or May 31 October 2011 June 8, 2011 Vascular 2 weeks or May 31 July 2011 May 27, 2011 Primary Care 2 weeks or May 31 May 24, 2011 May 24, 2011 Physical Therapy ASAP May 24, 2011 Blood Draw May 18 Walk-In

27 Transition Home to Ambulatory Care APPOINTMENT PHYSICIAN REGISTERED NURSE TELEPHONE TRIAGE Rehab X NONE Admin Assistant Neurologist Vascular X (with Nurse Practitioner) X (with Nurse Practitioner) NONE NONE Admin Assistant Admin Assistant Primary Care X NONE Medical Assistant Cardiology X NONE Admin Assistant Dermatology X NONE Admin Assistant Neurosurgery X NONE Admin Assistant

28 Acute Care RNs versus Ambulatory Care RNs Wendy Elizabeth RiAnn None Rachel and 2 nursing students Stacey Brightly Kate N Maria Shelle Jackie

29 Care Coordination and Transition Management Misconception #1 Acute Care is the point of access for individuals requiring care coordination and transition management, when in fact the ambulatory care setting is the point of access.

30 Misconception #2 A misconception that care transitions originate with a hospitalization rather than recognizing the multiple care transitions occurring among diverse ambulatory care settings.

31 Misconception #3 A misconception that a measure of care coordination and transition management is handing patients written instructions prior to discharge - a single intervention of a hand-off but not a measure of performance of care being coordinated or the transition being managed.

32 Misconception #4 A misconception that care coordination and transition management are discrete points of communication rather than a continuous conversation with ongoing communication.

33 Misconception #5 A misconception that individuals with complex health care needs are equipped with self-management skills and decision-making skills to know what to do when their condition worsens or they develop some complication.

34 Misconception #6 A misconception that individuals with complex health care needs seek care in traditional primary care settings, when diverse ambulatory settings are serving vulnerable populations including uninsured, Medicaid, and geographically and economically disadvantaged.

35 How are Professional Nursing Organizations Responding? American Academy of Ambulatory Care Nursing (AAACN) Fall 2011 AAACN Board Meeting discussed how to engage in moving the care coordination and transition management agenda forward.

36 How are Professional Nursing Organizations Responding? Convened a series of Expert Panels to delineate the RN competencies and develop an education program for care coordination and transition management in ambulatory care.

37 How are Professional Nursing Organizations Responding? Phase 1: Care Coordination Competencies Literature Review Team 26 members Worked in dyads Reviewed 82 journal articles and abstracted data to a table of evidence (TOE) January and February 2012

38 How are Professional Nursing Organizations Responding? Phase 2: Care Coordination Competencies Expert Panel 16 members, interprofessional representatives Worked as individuals using the original articles and TOE as source documents Dimensions Activities Knowledge/Skills/Attitudes March and April 2012

39 How are Professional Nursing Organizations Responding? Phase 3: Care Coordination Competencies Review Team

40 Dimensions Care Coordination and Transition Management Self-Management Education and Engagement of Patient and Family Team Work and Collaboration Nursing Process (assessment, plan, intervention, evaluation) Coaching and Counseling Cross Settings Transitions and Communication Patient Centered Care Plan Population Health Management Advocacy

41 Phase 4: Core Competencies Care Coordination and Transition Management Core Curriculum 13 Chapters/Modules 9 Dimensions plus Introduction Telehealth Informatics Transition from Hospital

42 Considerations Assuring the dimensions are patient centric Assuring the dimensions focus on individualized and ongoing patient plans of care across all micro and macro transitions Assuring the dimensions address contingency plans Assuring the dimensions guide patient and family access to open 24/7 communication networks

43 Inspire American Academy of Ambulatory Care Nursing (AAACN) Competencies for Care Coordination and Transition Management Haas, S., Swan, B.A., & Haynes, T. (2013). Developing ambulatory care registered nurse competencies for care coordination and transition management. Nursing Economic$, 31(1),

44 Inspire American Academy of Nursing (AAN) American Nurses Association (ANA) Delineating RNs essential roles in Patient care coordination. ANA Webinar Navigating New Frontiers: Nursing s Role in Care Coordination

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