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Team Presentation Coordinating Care Across all Settings

Team Presentation Coordinating Care Across all Settings. Complex Chronic Pediatric Center Learning Session 2 April 27-28, 2012. Disclosure.

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Team Presentation Coordinating Care Across all Settings

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  1. Team PresentationCoordinating Care Across all Settings Complex Chronic Pediatric Center Learning Session 2 April 27-28, 2012

  2. Disclosure I have no relevant financial relationships with the manufacturers of any commercial products and/or provider of commercial services discussed in this CME activity. I do not intend to discuss an unapproved/investigative use of a commercial productive/device in their presentation.

  3. Complex Chronic Pediatric Center • St. Josephs Children's Hospital Medical Arts Building • Currently a medical home for approximately 1000 patients • Team members: Dr. Daniel Plasencia Colleen Skaggs ARNP Jennifer LangRN Nurse Manager Margot Hasselbach RN CMS Joanie Mongie LPN Debbie Cone LCSW Lisa Andrews CCLS

  4. Aim Statement • By March 2012 St. Joseph’s Complex Chronic Pediatric Clinic will aim to improve our “Medical Home” by focusing on potential ways to improve our process for providing comprehensive, coordinated care across all settings. • Our goals include follow up appointments, comprehensive care plans, and care coordination. • We hoped to accomplish providing a complete understanding for our patients of their care plans so that they could better inform specialists, having readily available community resources as well as developing resources within our practice, co-managing our patients with their specialists on a more efficient level, and making sure that our patients were scheduling their return appointments at check out.

  5. Changes we made to get results • Our first change was to make sure that 90% of our patients scheduled their follow up appointment at checkout. • The MD or ARNP would inform the patient of the timeline in which they needed to return for follow up. At check out the receptionist would schedule the return appointment. The scheduled visit is then documented in the care plan that is given to the patient. • There is a on going list of patients that schedule their follow up appointment each day. • The results vary from day to day with an average of 85-90% of the patients scheduling their follow up appointment. • We learned that the challenges are patients who do not have calendars they follow are less likely to schedule due to not knowing when they will be able to return and even though they may schedule a follow up appointment it does not mean that they will actually show up for the appointment they scheduled. • The one change we made is we now provide patients with pocket day planners to better help organize their appointments.

  6. Changes we made to get results • Our second change was to provide each patient that is being seen for their WCC to receive a comprehensive care plan. • The MD or ARNP will print out the care plan and give to the patient along with any prescriptions or referrals. • Through our EHR we are able to track who received the care plans. • We have been able to provide 100% of the patients with the care plan. • We have learned that the patients appreciate the care plans and have had a positive response to receiving them. • We are now working on trying to provide the care plans at each visit if the patient would like to receive it.

  7. Changes we made to get results • Our third change was to document pertinent information from the specialists reports in the patient chart. • Our MD or ARNP reviews the reports. The ARNP is responsible for charting in the patient record within our EHR the information. • The ARNP signs off on the report that it has been documented within the patient chart. The report is then scanned into the patient chart. • By documenting the information directly into the patient chart we are able to monitor the compliance of appointments with the specialists and better co-manage with the specialists. • To date this has proven to be very effective.

  8. Results to Date

  9. Results to Date

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  11. Results to Date

  12. Results to Date

  13. Results to Date

  14. Results to Date

  15. Reflection • What we have learned from this “Medical Home” project is that if we develop processes and implement them into our everyday practice we can accomplish the goals we have set for us. It is important for everyone within our team to have a clear and concise idea of what their role is and the responsibilities of it. Continuing to utilize our EHR to track our patients so that they do not “Slip through the crack”. The biggest challenge we had was initializing the roles within the practice and defining the day to day responsibilities.

  16. Coordinating within our Practice • Since we are a closed practice and patients must be referred to us our coordination of care begins at the referral. • Our MD or ARNP are consulted on all referrals from the NICU and see the patient prior to discharge. At this time they make any recommendations and write orders for anything we would like to be done prior to discharge. • Since our physicians our the hospitalists at St. Joseph’s Children’s Hospital most of the referrals coming from inpatient come from them. The exception to this would be the patients coming out of the CICU or the PICU. In this case we are involved with the discharge nurse and the social work on the discharge plan and any family care conference that may occur.

  17. Coordinating within our Practice • Most of our patients have CMS and we are fortunate to have a CMS RN on site that works with us daily on the coordination of the patients. • Due to the location of our practice we are again fortunate that most of the specialists that our patients see our located on the same floor which helps in maintaining consistent care. • We direct admit from our clinic to the hospital to our same doctors who also see patients in the clinic. This provides for continuity of care and reduction of unnecessary tests being done on the patient.

  18. Coordinating within our Practice • The emergency room at St. Joseph’s Children’s Hospital has a read only access to our EHR providing a better continuity of care and allowing them to see medications, diagnoses, and the treatment plan. • Our social worker and child life specialist make home visits to assist with any needs inside the home. They also attend any school meetings with the parents to make sure the patients are receiving the proper resources within the school setting. • As we transition the patients out to adult providers the nurse manager or the social worker accompanies the patient to the first visit to assure the transition is seamless and provide any pertinent information to the provider taking over the care.

  19. Advice we would like to pass along • We believe that in order to have effective coordination of care you must know the specialists within your area that your patients see. • There must be an open line of communication so that they understand you are there to help them manage yours and their patients together to provide the best outcome for the patient. • It must be a team effort between the practice and the patient, with the patient understanding that you are partnering in the care with them.

  20. Thank you for allowing us to participate in this presentation

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