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Our ARC Journey…Professional Home Care Associates

Our ARC Journey…Professional Home Care Associates. Cheryl Haynes RN BSN Nursing Supervisor. Brief History:. Feb 2009- Valley Care shared their educational material for CHF with agency March 2009- Started post discharge collaboration Jan 2011- First ARC meeting with Valley Care

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Our ARC Journey…Professional Home Care Associates

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  1. Our ARC Journey…Professional Home Care Associates Cheryl Haynes RN BSN Nursing Supervisor

  2. Brief History: • Feb 2009- Valley Care shared their educational material for CHF with agency • March 2009- Started post discharge collaboration • Jan 2011- First ARC meeting with Valley Care • Feb 2011- Joined CHF PI team at Valley Care • March 2011- Started weekly case conferences on CHF patients with home care staff. • April 2011- Developed “CHF Red Flag” form • April 2013- Developed D/C review tool

  3. How We Connect to the Transitions Team at Valley Care: Weekly reports faxed to transition coach Phone calls as needed Ongoing support from Transition coaches with trouble shooting for complex/high risk cases Attend monthly PI meetings at hospital

  4. What is the process during Handoffs?

  5. The Process is simple: • T.C. from D/C planner about CHF referral & indicates patient is “CHF Protocol” • Home care receives H&P, updated D/C medication list, & orders • Intake coordinator communicates with Home RN that pt. is “CHF protocol” & gives copy of educational material to RN • Patient opened to home care day after hospital D/C (day 1) • Weekly reports faxed to Transitional coach until patient reaches day 30

  6. What Processes are Used to optimize communication? • Transitional Coach can call directly to RN following case (especially if coach is having trouble contacting pt. by phone) • Developed communication tool to MD- “Patient visit report” • Support/reinforcement by MD to pt/family • Patient/family hearing same information from medical team • Developed “CHF Red Flag” form to improve MD response time for patients showing symptoms

  7. Success: • CHF Red Flag form • Improved MD response time • CHF report form • Stream line reports from field RN’s

  8. Challenges: • Weekly case conferences before using report form. • Timely MD responses before “red flag” form • End of life issues/high risk patients • Social issues • Pt/family “buy in” regarding teaching

  9. Key take home messages: • Be patient…process doesn’t happen overnight! • Customize your process that will be feasible to your particular agency/hospital needs • Anticipate making changes to your process as you move forward….things don’t always go as planned.

  10. Outcomes: • Current CHF readmission rate is 19% • Now using D/C review tool to study reasons/trends in readmissions. • Plan- expanding program to other diseases (MI, Pneumonia)

  11. Questions?? • Contact information: • Cheryl Haynes RN BSN • Professional Home Care Associates • (925)243-1385 or email chaynes@prohomecare.com

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