What you need to know about Care Delivery at Temple!

1. What you need to know about Care Delivery at Temple! 2013 TUHS House Staff Orientation

2. Case Study Patient X is a 72 year old History of Present Illness: • chest pain, shortness of breath, palpitations, pedal edema Past Medical History: • hypertension, diabetes, atrial fibrillation, renal failure, heart failure, and frequent falls Exam: • blood pressure 180/98, heart rate 112, respiratory rate 26, pulse oximetry 95% 2L, afebrile • lungs- rales 2/3 bilat; irreg/irreg heart rhythm and rate; 2+ pedal edema; R Foot with erythema, warmth, tenderness; unsteady gait Ancillary testing: • Chest x-ray- CHF; BNP 2115; Creatinine 5.6 Admitted to Floor. Put on IV lasix, 02, imdur, beta blocker, and hydralazine. Also started on IV vanco

3. Care Delivery Issues Complex patient. Will need coordinated team effort to ensure safe and effective patient-centered care

4. Care Delivery Team Review Assessments and Roles of: • Physician • Nursing • Case Management • Social Work • Physical Therapy And how they all coordinate as a TEAM in providing Safe, Effective, Efficient, Timely, and Patient-Centered Care

5. Physician Assessment/Role • Clinical Assessment, treatment plan, and documentation • Plan for the Day, Stay, and Way • Work Rounds • Multi-disciplinary Rounds • Coordination of Care with Team • Medication Reconciliation • Patient and Family education • Transitions of Care

6. Accountable Care Unit Model Each Unit is geographic and has a: • Unit Based Medical Director who has oversight for the clinical, service, and cost outcomes of the Unit • Partnered management with nurse manager/UBMD leaders and structured multidisciplinary rounding Accountable for: • Efficiency of care • Patient throughput • Decreasing variation • Use of clinical care guidelines • Management of utilization • And teaching

7. Interdisciplinary Plan of Care - IPOC • Focus : IPOC is patient focused and disciplines add to the IPOC as they become involved in the patient’s care • Where : The IPOC is located in the Care Plan tab of the Medical Record

8. Falls Prevention • Any patient designated Low Risk or High Risk are placed in the Fall Prevention Program- Morse Scale used to assess fall risk • The yellow armband (At Fall Risk) is placed on the same arm as the patient ID band • The Fall Risk Magnet is placed by the patient name on the locator board outside the patient’s room and on the door frame. • Use of low rise bed and or bed alarms • Assure assistance and supervision are provided with elimination, transfers and ambulation • Provide patient/family education • Recommend referral to PM&R for safe ambulation and transfer techniques

9. What happens if a patient does fall? • A Midas Incident/Event report must be done. It needs specific information about the fall: Where, when, how, injuries? • Post Fall Assessment to be completed by the team • Falls are tracked and trended because of the Midas report • The data is used to help us improve care

10. Close Observation

11. Telemetry & Pulse Oximetry • Two classifications for telemetry • Class I (e.g. a-fib, a-flutter, certain medications) • If the patient needs to be transported, he/she must be on a cardiac monitor and accompanied by nurse or doctor (or both) • Class II (e.g. other diagnoses requiring monitoring) • The patient can be transported off telemetry and without a nurse or doctor • All patients requiring telemetry will have a patent IV access • Pulse Oximetry: • Verify the physician order for both telemetry and continuous pulse oximetry (pulse ox) • The order must include acceptable range for saturations

12. Discontinuing Telemetry • Patients eligible for removal of telemetry monitoring will be reviewed at shift report • Criteria for removal has been established under the direction of the Cardiology Medical Director • If patient meets criteria after 48 hours on telemetry, then an order must be obtained to discontinue telemetry • House staff/resident will be notified • Attending physician has the option of reordering telemetry

14. Department of Nursing

15. CLINICAL RESOURCE MANAGEMENT DEPARTMENT Primary functions- • Coordinate a safe and timely discharge plan • Secure reimbursement for care • Collaboration with the team • Daily Accountable Care Unit rounds • Review of medical record

16. What is needed from you? • H & P MUST be in the medical record for all members of the team to begin their work • Document patient’s contact numbers in H & P if you interview care giver • Clear documented plan of care • Forms and prescriptions completed timely • Communicate, Communicate, Communicate

17. How we can assist you? • Case Managers and Social Workers can assist you with developing the plan for a safe transition to after care • Consult with team to determine appropriate level of care for transition • Provide resources to you • Available as a resource to you and team

18. Patient incapable of decision-making No next of Kin Information Social Work to assess provision of resources in the community to local health district and public welfare office Patient admitted with a psychiatric involuntary (302) or voluntary (201) need for continued psychiatric treatment when medically stable Patient has active drug or alcohol issues Assistance in placement of Homeless patients When to consult Social Worker

19. When and Why Should Physical Therapy be Ordered? Is the patient at his functional mobility baseline? Will medical treatment alone restore the patient to his baseline level? Have there been attempts to mobilize the patient prior to therapy referral Is patient able to participate in therapy? Do you plan to transfer to a SNF or Rehab within the next 48 hours for PT services?

20. More about PT PT is contraindicated if: Spine not cleared from trauma/METS X-rays/MRI pending No clear Weight Bearing status Patient with BEDREST activity orders HgB <7 INR > 5 PT is not necessary if: Safely discharging home Want home PT for endurance or safety check Want outpatient PT for chronic issues Patient is baseline functionally Want a walking pulse ox

21. Other PM&R Services

22. Case Management-Discharge Planning Considerations- Home Care • Visiting Nurse • PT • IV Therapy • OT • Speech • Home care aide • Home Hospice Skilled Facility • PT needs • Wound Care • Wound Vac • IV antibiotic therapy • Inpatient Hospice • Needs insurance authorization • Acute Rehabiltation • Needs qualifying diagnosis • Insurance authorization • PM&R team will provide physical, occupational, and speech therapies

23. Coming Back to our Patient • Physical Therapy evaluation indicates patient would benefit from inpatient PT, not safe for home discharge • Medical team indicates patient will be discharged on intravenous antibiotics • Chronic Dialysis needed, new onset, Social Work needs to arrange for a unit to accept patient

24. Discharge Coordination • Skilled facility placement must be coordinated with the dialysis Social Worker • Patient agrees to Hemodialysis site and Skilled Nursing Facility • Insurance Authorization must be obtained • Patient medically cleared for transfer-documented • Final arrangements made, time of transport communicated • Transfer orders complete before time of discharge

25. Alternative Discharge Plan • Patient has made progress in physical therapy • Therapist recommends continued PT at Home • Team modifies medication regime to insure adherence • Case Manager informed of plan and suggests Visiting Nurse, PT and Home Health Aide • Home infusion arrangements • Agency selected; must coordinate with Hemodialysis • Informs team, discharge instructions completed

26. Temple Access Center Need an appointment for a patient being discharged? • Place an order in MIS (Computerized Physician Order Entry system)- it goes to our Access Center • 2 hour turn around time for referral in-system/24 hours for external referrals • Access Center will make the appointment and enter it directly into MIS in the discharge instructions

27. Summary • Patients are complex • Care Delivery requires a multidisciplinary approach and great teamwork • Take advantage of your Temple Team- everyone is here to help you provide safe, efficient, effective, timely, equitable and patient centered care • Welcome to your TUHS experience!