Transcript Optimizing Transitions of Care: Redesigning nursing roles

Improving Patient Transitions:
Building Social Networks across
the Care Continuum
Suneela Nayak, MS RN
Nan Solomons MS
Shelly Shibles, BSN RN
Learning Points
• Focus on Avoidable Readmissions:
Why now?
• How do social network theories help
nurses improve safe patient transitions?
Why Now?
Avoidable readmissions :
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Frequent & costly
Issue of quality of care and patient safety
Source of dissatisfaction
Waste increasingly scarce resources
Focus on Reduced Readmissions…
Offers Abundant Opportunities for Nurses to
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Advocate for patient’s agenda for care
Focus on safety, improved outcomes
Develop ability to network across continuum
Fully engage clinical skills, scope of practice
MaineHealth
Transitions of Care Bundle
1. Risk stratification for readmission
2. Transition Checklist
3. Medication reconciliation
4. Patient/family health education
5. Timely communication among hospital
and post-hospital providers
6.Timely follow-up of patients
Leading with Innovation
What are
Social Network Theories?
Social Network Theories
Social networks consist of:
nodes (people)
ties (relationships)
Social Network Theories
Outgoing
tie
S
1-way
Isolate
Incoming
tie
Strong Tie
2-way
Weak Tie
Boundary
Spanner
Social Network Analysis
ED
LTC
Hospital
PCP
MedSurg
LTC
Specialty
Discharge
Planner
Records
Pharmacy
SNF
Home
Health
Social
Services
Leading with Innovation
How do
Social Network Theories
Help Nurses
Improve Patient Transitions?
Evolution of Our Team
2009
Cardinal
Health
Grant
Team
2010
Stephens
Memorial
Hospital
Transitions
Team
2011
WMHC
CrossContinuum
Team
2012
WMHC
CrossContinuum
Team
(Expanded)
2009 Stephens Memorial Hospital:
Cardinal Health Grant Team
RN
PT
MaineHealth
QI
SW
RN
Mgr
Acute Care
Group
Physician
Practice 1
OT
IT
Rx
Care
Transitions
Coach
Hospice
H-H
Cardinal
Health Team
2010: Stephens Memorial Hospital
TransitionsTeam
QI
Patient
Care
Facilitator
SW
MaineHealth
PT
RN
RN
Mgr
Acute Care
Network
IT
Physician
Practice 1
OT
Rx
CT
Coach
Hospice
H-H
Stephens’s
Memorial Hospital
Transitions Team
LTC
RN
Dir,
LTC
Improving Transitions:
Next Steps
• 2011: CMS quoted the SNF Readmission
Rates at 19.8%
• Next Step:
Network with regional Long Term and
Skilled Nursing Facilities
Western Maine
Long Term Care Network
Physician
Practice 2
Long
Term Care
Network
Physician
Practice 1
2011: Western Maine Cross
Continuum Network
MaineHealth
PT
RN
SW
QI
Patient
Care
Facilitator
RN
Mgr
IT
Physician
Practice 2
OT
Physician
Practice 1
Rx
RN, LTC
Hospice
H-H
Care
Transitions
Coach
Director
LTC
2011: Western Maine Cross
Continuum Network Ties
MaineHealth
Physician
Practice 1
HomeHealth &
Hospice
Stephens
Memorial Hospital
Transitions Team
CT
Coach
Physician
Practice 2
Long Term
Care Admin &
Staff
Our Transitions Team Today:
Increased:
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
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

Comfort
Trust
Teamwork attributes
Engagement
Ease of referral
Social Worker invited to travel to nursing homes
Meetings run over time, no one leaves
Daily phone conversations for early problem solving
Our Next Steps…
Who else should be at the table?
2012: Western Maine Expanded
Cross Continuum Network
MaineHealth
Physician
Practice1
EMS
HomeHealth &
Hospice
Acute Care
Team
Care
Transitions
Coach
EMS
Long Term
Care Admin
& Staff
Physician
Practice2
EMS
Patient
So…
How has all this
improved outcomes
for our patients?
MaineHealth Readmission Rates:
Outcome Measures
MaineHealth System Performance
Q1 FY 2008 - Q3 FY 2011
22%
21%
20%
19%
18%
17%
16%
15%
14%
13%
12%
Q1 FY
2008
Q2 FY
2008
Q3 FY
2008
Q4 FY
2008
Q1 FY
2009
Q2 FY
2009
State : 80th Percentile
MH System
Q3 FY
2009
Q4 FY
2009
Q1 FY
2010
Q2 FY
2010
Q3 FY
2010
Q4 FY
2010
Q1 FY
2011
National: 80th Percentile
National 10th Percentile
Q2 FY
2011
Q3 FY
2011
Improving Patient Transitions:
Building Social Networks across the
Care Continuum
Questions?
Suneela Nayak, MS RN
Nan Solomons MS
Shelly Shibles, BSN RN