Presented by: Lisa Van Dyck VP Product Development & Consulting VNA First / Innovative Healthcare Solutions Ensure Best Practice & Great Outcomes with Clinical Pathways Outline Predictive Controlled Care Consistency Clinical Pathways Continuity Compliance Clinical Pathway Evidence Based Practice Standards Introduction Clinical Pathway Model Step by Step Approach Integration of Best Practice Brief Demo of a Visit Pathway Components Overview Visit Note CoSteps Care Management Dashboard Focus Assessments Summary Available Support 2010 VNA First/Innovative Healthcare Solutions 1
Supporting Self-Management Step by Step Tools Empower patients to take control of their condition Recognize their own accountability Self manage Change behaviors Be actively involved Prepare for visits Clinicians: consistent teaching A Pathway for the Patient/CG! Routine Visit Demo 2010 VNA First/Innovative Healthcare Solutions 2
Clinical Day View Clinical Day View: Pathway Status 2010 VNA First/Innovative Healthcare Solutions 3
Plan Overview: Focus Assessments 130/80-180/90 2010 VNA First/Innovative Healthcare Solutions 4
Visit Note: Disease Process Document Assessment Findings as per agency procedure Document Assessment Findings as per agency procedure Test/Treatments Document Assessment Findings as per agency procedure 2010 VNA First/Innovative Healthcare Solutions 5
Medications Medication Profile Link 2010 VNA First/Innovative Healthcare Solutions 6
Med Sheet - Update Ed Tracking Nut/Hyd/Elim 2010 VNA First/Innovative Healthcare Solutions 7
Activity Document Assessment Findings as per agency procedure Safety Document Assessment Findings as per agency procedure 2010 VNA First/Innovative Healthcare Solutions 8
Psychosocial Document Assessment Findings as per agency procedure Interteam / Community (HCA Sup) Document Assessment Findings as per agency procedure 2010 VNA First/Innovative Healthcare Solutions 9
Validate Complete Note: Plan: Repeat Step 2010 VNA First/Innovative Healthcare Solutions 10
Components Overview Care Focus Groups Goals Focus Assessments Visit Notes: Step-specific Interventions, Outcomes, Assessment Findings Disease Process Tests and Treatments Medication Nut/Hyd/Elim Activity Safety Psychosocial Interteam/Community Variance Codes, CoSteps, Other Tools, Standard Orders Dashboard Dashboard: Variance Summary 1E Discharge or Not? 2010 VNA First/Innovative Healthcare Solutions 11
Review: Routine Visit Best Practice Clinical Day View Dashboard Bumps in the road.. Trends in variance codes Add Pathway Step View Plan View Focus Assessments Perform interventions, assessments Evaluate outcomes Validate Share with Patient/CG Confirm Plan for next visit Your done! Components to look forward to Standard Orders integrated into pathway M2250 Recommended visit frequency standard Recommended visit/contact frequency high risk ACH Editable Populate to 485/Orders OASIS C Process Indicator report or visit companion (Transfer & D/C) 2010 VNA First/Innovative Healthcare Solutions 12
Summary & Q/A Consistency Continuity Compliance Demonstrate your agency has the tools necessary to be an essential partner for success within the Healthcare Reform environment! Summary & Q/A Patient (Outcome) Driven Care, Step by Step EVERY VISIT COUNTS: Focused care every visit encounter Outside visit time, orientation time, care coordination time, QA/QI time Evidence based practice Standardized Care Move patient from Safety, to Disease Control, to HP Step 5 = Safety, starting Disease Control Individualized care on the fly Overview, Variance codes, CoSteps, repeat steps, combine steps, PRN visits, extended care protocols Define a visit encounter, an episode or a population of patients (variances against a standard of care) 2010 VNA First/Innovative Healthcare Solutions 13
Summary & Q/A Proactive Chronic Disease Management Pathways have demonstrated to reduce ACH and ER use Core interventions and outcomes re: to PREVENTION of injury/falls, ACH, ER, exacerbation Problematic Key OASIS (HHQI) outcomes - evaluate and actively intervene every visit until at expected goal Dashboard/Tracking Tool promotes making changes to plan TODAY, not waiting until a care conference, recert time or a retrospective chart review Step by Step Patient Ed Tools Promote reaching end of pathway with less resources Produce Great Outcomes ~ Value Based Purchasing! Questions? VNA First / Innovative Healthcare Solutions offers Education /Consulting Pathway implementation Disease management Step by Step Patient Ed Books & Tear Off sheets; Stoplight Tools Clinical Pathways Disease Management Resources Private Duty Resources for Disease Management www.innovativehcs.com Free videos Other programs, products Educational offerings lvandyck@vnaf.org 630-236-4607 2010 VNA First/Innovative Healthcare Solutions 14