RT AS PROJECT
MANAGER
:
IMPROVING CARE TRANSITIONS
DECREASES UNPLANNED READMISSIONS
TAMMY JARNAGIN, BHS, RRT
DIRECTOR CARDIOPULMONARY SERVICES,
Objectives
•
Recognize leadership opportunities for a Respiratory
Therapist
•
Key process improvement techniques to include
during project management.
•
Share our journey and how we incorporated
evidence-based, best practice components into the
MGMC transition care program
MGMC’s Improvement Model
FOCUS –
P
D
C
A
Find a Process to Improve
Organize a Team that Knows the Process
Clarify Current Knowledge of the Process
Understand Causes of Process Variation
Select the Process Improvement
Act Plan
To Hold Gain Process Improvement
To Continue Improvement
Check Do
Data from Improvement Implement Plan
Additional Incentives
Improve HCAHPS “Care Transitions” Questions
During this hospital say, staff took my preferences and
those of my family or caregiver into account in deciding
what my health care needs would be when I left.
When I left the hospital, I had a good understanding of the
things I was responsible for in managing my health.
When I left the hospital, I clearly understood the purpose
for taking each of my medications
Improve HCAHPS “Discharge Information”
Questions
During this hospital stay, did doctors, nurses, or other
hospital staff talk with you about whether you would have
the help you needed when you left the hospital?
During this hospital stay, did you get information in
COPD Readmissions
•
700,000 hospitalizations in US with principal dx of COPD
Only 50% received guideline treatment.
•
How to use their medications – ie inhaler, oxygen
•
Arrange a post discharge appointment for follow-up
•
Including Pulmonary Rehab and Smoking Cessation
•
1 in 5 (23%) readmitted within 30 days
•
Contributing – access, quality, coordination of care
post-discharge, socioeconomic
•
Half of the estimated $50 billion in health care expenditures
for COPD attributed to costs associated with hospitalizations
for COPD exacerbations.
•
We can do better!!!
Evidence-based Resources
•
COPD Foundation
•
VA research and articles
•
Dr. Eric Coleman, Div. of Healthcare Policy & Research,
Univ. of Colorado, Director of Care Transitions
www.caretransitions.org
•
Evidence-Based Programs
•
Society of Hospital Medicine’s (SHM) Program
•
BOOST – Better Outcomes through Optimizing Safe Transitions
•
RED – Project Re-engineering Discharge
•
Care Transitions Intervention
Development of Transition Care Program at MGMC
Purpose:
◦
Reduce avoidable readmissions by improving
transitions in care (care coordination)
Targeted Patient Populations:
◦
Pilot (test of change):
◦
Chronic Obstructive Pulmonary Disease (COPD)
◦
Integration:
◦
Heart Failure (CHF)
◦
Acute Myocardial Infarction (AMI)
Key Components of Transition Care Program
Patient Identification --- “Transition Care Patient”
Daily Multidisciplinary Discharge Planning Meetings
Bedside Multidisciplinary Team – includes family
Standardized Educational Materials & Self Management Plan
Follow-Up with Physician Within 3 – 5 Days of Discharge
Free Transition Homecare Visit : 24 – 48 Hours of Discharge
Follow-Up Phone Calls by First Nurse
Referrals to Continuum of Care Programs –
Pulmonary Rehab, Cardiac Rehab, etc
COPD checklist
COPD Transition Care Checklist:
___ Patient Education Completed (RN & IDT)
___ Video: Channel 4 “COPD: Take Control” (RN)
___ Booklet “Living Life to the Fullest with COPD” (RN & IDT)
___ Stoplight Self-Management Plan (RN & IDT)
___ Transition Care program (RN give letter to patient/family & review)
___ All educational materials in “Discharge Folder” (RN)
___ Discharge Instruction – including medication reconciliation (RN)
___ Schedule physician follow-up appointment scheduled within 3-5 days of
discharge -
Appointment made by patient’s nurse (M-F 8-5pm). For discharges on weekends, patient directed to make PCP appointment in 3-5 days. HOMEWARD will validate or arrange appointmentduring visit and validate transportation arrangements.
___ Call HOMEWARD for Free Transition Care Home visit (RN) –
HOMEWARD referral line 515-233-7517
COPD Self-Management Home Plan
Symptoms or health problems to look out for after you leave the hospital
HOME-MANAGEMENT PLAN FOR CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) Green Zone = “All Clear”
Your Normal Weight ___________
I am breathing normally for me I can do my usual activities
My mucus (phlegm) is usual color and amount I do not have a fever or chills
I can think clearly
Green Zone Means:
Taking your medications
Continue daily activities and regular exercise Wash hands often, avoid people with a cold Stop smoking, avoid second-hand smoke Eat healthy foods and drink clear fluids Keep doctor appointments
Yellow Zone = “Caution”
If you have any of the following signs or symptoms:
I am having increased shortness of breath or wheezing
My cough is worse or mucus (phlegm) increases or changes in color I am tired and can’t do regular activities
I have a fever or chills I have diarrhea or rash I am not thinking clearly
Yellow Zone Means”
Limit activities, get plenty of rest
Continue with all prescribed medications, including breathing treatments (if ordered)
Call your primary doctor or First Nurse First Nurse:
Ames: 515-239-6877 Marshalltown: 641-754-6877 Anywhere in Iowa: 800-524-6877
Primary Doctor/Number:___________________
RED ZONE= “Medical Alert”
I have more trouble breathing
I have more trouble coughing up mucus (phlegm) I can’t do my usual activities
I am sleepy, difficult to wake up, or confused I have slurred speech or feel faint
Change in the color of my skin,my nail beds or lips are gray or blue
Red Zone Means: Call 911 or go to the emergency room.
COPD Symptom Tracker
Daily Symptom Tracker
D
at
e
Breathing
My Normal
More short of breath
In trouble Mucus Phlegm
My Normal
More mucus, worse cough
Can't coughup mucus Activity
My Normal
More tired with regular activity
Can't do regular activity
Temperature Fever
My Normal
I have chills or fever
I have a Fever ( ) Thinking
My Normal
I'm not thinking clearly
I'm confused or hard to wake up
Other
I have a Rash
I have diarrhea
I have slurred speech
I have blue lips , nails
Action I called First Nurse
