1. Massachusetts STAAR October 11-12, 2011 Saints Medical Center Cross-Continuum Team

2. STAAR Cross-Continuum Team • Our Experience Re-Convening a Cross-Continuum Team • Development and Use of a Handoff Communication Quality Improvement Tool

3. Saints Medical Center • 157-bed Community Hospital • Serves Greater-Lowell and Merrimack Valley since 1839 • Primary and Acute care services to 315,000 residents from 25 communities

4. Readmissions • In 2009 • Heart Failure Readmission Rate • 27.9% (among highest in nation) • Joined STAAR September, 2009

5. How-to-Guide: Convene a Cross-Continuum Improvement Team • Implementing change • Conduct Small Tests of Change • Don’t wait until it’s perfect • Dive in • Do it today • Membership - Who? • SNF and HHA Liaisons • Monthly meetings December, 2009 – June 2010

6. Through the Eyes of an Early Cross-Continuum Team Member • Staff level involvement • Liaisons happy to participate • Shared information with administration • As clinical leader, felt need to participate

7. Through the Eyes of an Early Cross-Continuum Team Member • First meetings • Getting to know each other • Group Assessment • Tools, Processes • Educational Materials • Best Practices, Standards of Care • Regulatory Reporting Requirements

8. Through the Eyes of an Early Cross-Continuum Team Member • By June, 2010 • Recognized need to standardize care • HHA – Hospital to Home Pathway • SNF - INTERACT

9. Tests of Change • Plan: split into HHA and SNF subgroups • Re-evaluate appropriateness of team membership • Blow it up and start over • “Moving into the next phase” • Membership to include Administrators and Clinical Leaders that could impact change in their facilities

10. Community Partners Elder Services of Merrimack Valley - Mary DeRoo, Home Care Director Home Health VNA - Patricia Finocchiaro, Clinical Director VNA of Greater Lowell - Irene Sommers, Director of Clinical Services CareTenders - Michael Guarnieri, Executive Director Blaire House of Tewksbury - Paula J. Drelick, RN NHA D’Youville Senior Care - Cynthia Thornton, RN, Director of Nursing Fairhaven Healthcare Center – Alex Struzziero, Administrator Saints Medical Center Debbie Staniewicz, RN Day-To-Day Leader STAAR, Dir. Nursing 3E, 4A Deborah McCrady, Dir. Case Management Ellen Scott, RN Dir. Nursing ICU, Telemetry, 5P Janet Liddell, RN Day-To-Day Leader STAAR, Quality Improvement Coordinator Kim Richardson, RN, Dir. Outpatient Satellites Wingate at Lowell - Diane Tessier-Efstahiou, Adminstrator Heritage Nursing Care Center - Elizabeth Rozzi, Administrator Palm Manor - Frank McGuire, Administrator Willow Manor - Robin Fortin, Administrator Radius Northwood HeathCare Center – Michele Desmarais, Executive Director Life Care Center of Merrimack Valley - Colleen Lovering, Executive Director NEQCA – Tufts - Jennifer Mercier, RN Amedisys HHA – Kimberley Brown, RN Dr. S. Ramya, Hospitalist, Executive Leader STAAR Helene Thibodeau, CNO, VP Q&PS, Executive Leader STAAR Judith Casagrande, COO Jennifer Braga, Dietician Lisa Conte, RN, Nurse Manager, Dialysis STAAR Cross-Continuum Team

11. STAAR Cross-Continuum Team New Team Composition: • Great Attendance and Meeting Participation • Needed working group • Formed a Sub-Committee • Enhanced Teaching and Learning • Quickly Accomplished Objectives

12. STAAR Cross-Continuum Team • July 2011 Team’s Priority Work • TJC and Health Care Proxy • Full Code vs. DNR • Revised HF Teach Back w/ weights • Insurance Contract requirements • Sub-Committee • Handoff communication • QI Tool

13. Handoff Communication QI Tool

14. Handoff Communication QI Tool

15. Handoff Communication QI Tool • Used by HHA and SNFs • To assess patient information sent to next care provider • Conducted case reviews at HHA

16. Findings • Highlighted processes that were working • Medication reconciliation • Scheduled MD appointment • Uncovered inconsistencies and discrepancies • missing documents i.e., health care proxy, discharge summaries, teach back with weights

17. Plan, Do, Study, ACT • Tested the tool • Presented findings at sub-committee and revised tool • Led to major areas of interest and opportunity for focus within the hospital and across the continuum to improve handoff communication and transitions in care.

18. Contact Information Janet Liddell, MSN/MBA, RN, QI Coordinator Saints Medical Center One Hospital Drive, Lowell, MA 01852 (978) 458-1411 x4089 jliddell@saintsmed.org Patricia Finocchiaro, RN, MS, Director Clinical Services Home Health VNA (978) 552-4124 pfinocchiaro@homehealthfoundation.org Heidi Landers, RN, BSN, MHA, Lowell Branch Manger Home Health VNA (978) 569-1704 hlanders@homehealthfoundation.org