Nurses: Architects of an Integrated Healthcare Delivery System. Billie Lynn Allard, MS, RN Administrative Director of Outpatient Services

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1 Nurses: Architects of an Integrated Healthcare Delivery System Billie Lynn Allard, MS, RN Administrative Director of Outpatient Services Presentation ID: 338 1

2 Disclosure Today s presenters do not have any relevant financial interests presenting a conflict of interest to disclose. Participants must attend the entire session(s) in order to earn contact hour credit. Continuing Nursing Education credit can be earned by completing the online session evaluation. The American Organization of Nurse Executives is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation. AONE is authorized to award one hour of pre-approved ACHE Qualified Education credit (non-ache) for this program toward advancement, or recertification in the American College of Healthcare Executives. 2

3 Objectives Partner with key customers and stake holders to design a local, integrated healthcare delivery system Respond to care and assess gaps in your community by redeploying existing resources Formulate a care delivery implementation plan, gaining endorsement and support for necessary resources 3

4 Southwestern Vermont Healthcare Community Hospital Setting Cancer Center Medical Offices Long Term Care Hospital United Counseling 4

5 SVHC is a Health System part of One Care ACO OneCare Vermont 2 Academic Medical Centers 13 Community Hospitals 1 Behavioral Health Facility 2 Federally Qualified Health Centers 5 Rural Health Clinics 58 Private Practices 280 Primary Care Physicians 42,000 Medicare beneficiaries 5

6 Clinical Nurse Specialists in the Future Visualization Exercise at Retreat 6

7 Naylor Model Transitions of Care of 7

8 Working with the CFO Fee for Service Global Budget 8

9 Patient is introduced to the TCN during a scheduled visit. Patient Transitions to Subacute Care TCN does warm hand off and participates in care plan Primary Care Provider (PCP) Patient Transitions Home Patient Transitions to Hospital TCN shares pertinent data with care team. TCN visits patient within hours of notification to review discharge plan, assist with medication reconciliation, plan referral appointments, and provides plan for symptom management, what they can expect and what actions to take 9

10 One TCN One Practice (Village Primary Care) 10

11 Transitional Care Program Social work Pharmacist Diabetes educator Respiratory Therapist Lifeline Nursing Home Medicaid case manager Physical Therapy Dietician Assisted Living Rehab Center Transitional Care Patient and Family Team Home Meals on Wheels Hospice Hospital VNA Hotel Hostel (homeless) Soup Kitchen Council on Aging Emergency Department PCP office Adult Daycare United Counseling Services Physicians (specialists) SASH Case Management (Hospitals) 11

12 Fresh eyes can see clearly ED Care Plan Development Medication Reconciliation CHF/COPD Care Pharmacy Consultation and Education Transitions of Care (Gap Analysis) Community Care Team Integrated Diabetes Education Social Work Access Interact 12

13 Redeployment of Hospital Resources 13

14 Challenges No thank you! from Medical Home Overlap of services with home care nurses Why masters prepared nurse? Clarity of role explanation and communication Early identification of patients by health team 14

15 Where we are now Regional Clinical Performance Committee Contract with CMS Jan 2017 (Maryland plan) 4 TCNs partnered with all PCP offices 15

16 Reducing the actual cost of care 16

17 Reducing the actual cost of care 17

18 Gaps Solutions Standardization of care Clinical Pharmacist Pulmonary Rehab Interact Implementation Community Care Team 18

19 Daily Huddle 19

20 Relationships Building Northshire Medical Center Medical Home Case Manager Nursing Home Admission Nurse 20

21 Interact Implementation 21

22 Community Care Team (Program modeled after Middlesex Hospital, Connecticut) 22

23 Plugging the gaps Outpatient Dietitian Diabetes Education Respiratory Therapy Rehabilitation 23

24 Clinical Pharmacist 24

25 Integrated Social Work 25

26 Visiting Nurse relationship 26

27 Future Nursing Curriculum 27

28 Grant Funding Care Fusion VHCIP (State of Vermont) Hillman Foundation finalist 28

29 Patient Satisfaction Tool 1. My Transitional Care nurse helped me feel more confident that I can manage my medications. 2. My Transitional Care nurse helped me learn about my illness and how to manage it better. 3. My Transitional Care nurse helped me learn when to call the doctor, go to the emergency room or call 911. Always Usually Seldom Never Does not apply to me The nurse worked with me to enforce the importance of taking my medication and how to stay healthy. I was also educated on signs to watch for before this situation could go bad. I just look at my refrigerator and then I know when I need to call the Doctor. Since I ve been in the Transitions of Care program, I weigh myself everyday. 29

30 Quality of Life 30

31 CPT Codes for Transitions Center for Medicare and Medicaid Services and major insurance carriers The health care professional accepts care of the beneficiary post discharge from the facility setting without a gap. 31

32 Sharing our story. Geriatrics 2014 Evolving Role of the Transitional Care Nurse in a Small Rural Community Jennifer Fels, MS, RN, Billie Lynn Allard, MS, RN, Karen Coppin, MSN, RN, CEN, Karen Hewson, MSN, RN, and Barbara Richardson, MSN, RN-BC, CCRN Home Health Care Journal 32

33 Shift in utilization (lower cost setting) for residents of Bennington County. 33

34 Shift in utilization to primary care (lower cost setting) for residents of Bennington County. 34

35 Transitional Care Nursing -- Bennington, Vermont Comparison of ED Visits and Hospital Admissions Before/After TCN (n=101 patients on TCN program 120 days) Encounters Type 0 Before TCN After TCN ED Visits Before TCN After TCN Hospital Admissions Data Source: SVMC ED Visits September 2013 through September

36 Most recent data placeholder 36

37 Most recent data placeholder 37

38 Most recent data placeholder 38

39 Future Legislative Advocacy 39

40 NURSES Nurses created the synergy, capitalized on relationships, broke through resistance, waited patiently, worked tirelessly, produced results, shared data, leveraged opportunities and empowered patients. Patient Centered Integrated Care Delivery 40

41 The Beginning Helen Fairchild Florence Nightingale Mary Seacole Mary Mahoney Clara Barton 41

42 Nursing Leadership 42

43 TCN Nurse 43

44 Clinical Nurse Specialist 44

45 Maternity Nurses 45

46 CEO, CNO, Director Of Inpatient Services and MPD 46

47 Pulmonary Rehab 47

48 Medical Surgical Nurse 48

49 Long Term Care Leadership 49

50 Medical Surgical Nurses 50

51 Renal Dialysis Nurse 51

52 2013 Magnet Conference 52

53 Cardiac Nurse 53

54 Emergency Department Team 54

55 Special Procedure Nurse 55

56 TCN s and MPD 56

57 Maternity Nurses 57

58 Endoscopy Team 58

59 Operating Room Nurses 59

60 Nursing Professional Day 60

61 Visiting Nursing Association 61

62 Labor and Delivery Nurse 62

63 Peri-operative Nurse 63

64 Nurse Interns and Educator 64

65 Pediatric Nurse 65

66 Cardiac Rehab Team 66

67 Intensive Care Nurse 67

68 Architects of Healthcare Delivery LET S DO IT!

69 Thank You Billie Lynn Allard, MS, RN Southwestern Vermont Health Care 100 Hospital Drive, Bennington, Vermont (phone) 69

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