October 30, The Transitional Care Experience

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The Transitional Care Experience

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The Transitional Care Experience

Beth Ann Swan, PhD, CRNP, FAAN

Dean and Professor

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Who Do I Know in Chicago?

The Professional Network

Primary Contacts

Sheila Haas

Regina Phillips

Kathy Krone

Secondary

Fran Vlasses, Loyola Michelle Janney, CNO

Carol Payson

Alan, Nurse Manager Anna McKee, JC

Rita Axelrod’s son, NICU attending

Tertiary

Former students from Loyola who knew Ida Androwich

Current Loyola students: Elizabeth, Eric’s nurse was a Loyola grad; Alan

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Acute Care Hospitalization:

Registered Nurses

Elizabeth RiAnn Stacey Kate Jackie Shelle Maria Brightly Rachel and 2 nursing students Wendy

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Micro and Macro Transitions

• Neuro ICU

• Neuro Step Down Unit

• General Unit

• Acute Care Hospitalization

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Inpatient Rehabilitation:

Registered Nurses

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Macro Transitions

• Acute Care Hospitalization

• Acute Inpatient Rehabilitation

• Home

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Discharge to Home

• Handed a 10-page Rehabilitation Discharge Instructions Report

• Report listed need to schedule five appointments including: • Rehab Physician within 3 weeks

• Neurologist within 2 weeks

• Vascular/Antithrombotic Service within 2 weeks • Primary Care Provider within 2 weeks

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Discharge to Home

• Required to have blood draws for INR, first blood draw the next day

• Given seven prescriptions along with 29-pages of printed information

• Handed 5-pages of instructions for home safety

• Handed 6-pages of addresses for Outpatient Rehab facilities • Handed a hand-written list of four community stroke support

groups

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Discharge to Home

• Three prescriptions were filled before leaving the hospital • Arrived home at 1PM

• Received telephone call at 4:45PM that Eric’s lab values were not checked before leaving hospital and now he requires different dosages of the two of the three

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Sampling of Charges

• Bill for 911 for transport from O’Hare International to Community Hospital = $1,149

• Community Hospital = $23,312 (less than 24 hours)

• Bill for ambulance transfer from Community Hospital to Northwestern Memorial = $2,130

• Physician Charges to Read Imaging = $2,117 • Physician Charges – one service = $1,380

• Hospital Services = $77,689 including room and board ($33,750); pharmacy ($1,306); radiology ($14,719); med-surg-anesth supplies $85.00; laboratory ($20,988); rehab ($3,689); cardiology ($3,152)

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Coordinating Care and Managing Transitions

APPOINTMENT PRESCRIBED NEXT

AVAILABLE

SCHEDULED Rehab Physician 3 weeks or June 7 June 9, 2011 June 9, 2011 Neurologist 2 weeks or May 31 October 2011 June 8, 2011 Vascular 2 weeks or May 31 July 2011 May 27, 2011 Primary Care 2 weeks or May 31 May 24, 2011 May 24, 2011 Physical Therapy ASAP May 24, 2011

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Transition Home to Ambulatory Care

APPOINTMENT PHYSICIAN REGISTERED

NURSE

TELEPHONE TRIAGE

Rehab X NONE Admin Assistant

Neurologist X

(with Nurse Practitioner)

NONE Admin Assistant

Vascular X

(with Nurse Practitioner)

NONE Admin Assistant

Primary Care X NONE Medical Assistant

Cardiology X NONE Admin Assistant

Dermatology X NONE Admin Assistant

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Acute Care RNs versus Ambulatory Care RNs

No ne N Elizabeth RiAnn Stacey Kate Jackie Shelle Maria Brightly Rachel and 2 nursing students Wendy

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Care Coordination and Transition Management

Misconception #1

• Acute Care is the point of access for

individuals requiring care coordination

and transition management, when in fact

the ambulatory care setting is the point

of access.

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Misconception #2

• A misconception that care transitions

originate with a hospitalization rather

than recognizing the multiple care

transitions occurring among diverse

ambulatory care settings.

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Misconception #3

• A misconception that a measure of care

coordination and transition management

is handing patients written instructions

prior to discharge - a single intervention

of a hand-off but not a measure of

performance of care being coordinated

or the transition being managed.

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Misconception #4

• A misconception that care coordination

and transition management are discrete

points of communication rather than a

continuous conversation with ongoing

communication.

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Misconception #5

• A misconception that individuals with

complex health care needs are equipped

with self-management skills and

decision-making skills to know what to

do when their condition worsens or they

develop some complication.

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Misconception #6

• A misconception that individuals with

complex health care needs seek care in

traditional primary care settings, when

diverse ambulatory settings are serving

vulnerable populations including uninsured,

Medicaid, and geographically and

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How are Professional Nursing

Organizations Responding?

• American Academy of Ambulatory Care

Nursing (AAACN)

• Fall 2011 AAACN Board Meeting discussed

how to engage in moving the care

coordination and transition management

agenda forward.

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Organizations Responding?

• Convened a series of Expert Panels to delineate the

RN competencies and develop an education

program for care coordination and transition

management in ambulatory care.

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• Phase 1: Care Coordination Competencies

Literature Review Team – 26 members

• Worked in dyads

• Reviewed 82 journal articles and abstracted data to

a table of evidence (TOE)

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• Phase 2: Care Coordination Competencies Expert

Panel –

16 members, interprofessional representatives

• Worked as individuals using the original articles

and TOE as source documents

• Dimensions – Activities –

Knowledge/Skills/Attitudes

• March and April 2012

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• Phase 3: Care Coordination Competencies

Review Team

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Dimensions

• Self-Management

• Education and Engagement of Patient and Family • Team Work and Collaboration

• Nursing Process (assessment, plan, intervention, evaluation) • Coaching and Counseling

• Cross Settings Transitions and Communication • Patient Centered Care Plan

• Population Health Management • Advocacy

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Phase 4: Core Competencies

• Core Curriculum

• 13 Chapters/Modules

• 9 Dimensions plus

• Introduction

• Telehealth

• Informatics

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Considerations

• Assuring the dimensions are patient centric

• Assuring the dimensions focus on individualized

and ongoing patient plans of care across all micro

and macro transitions

• Assuring the dimensions address contingency plans

• Assuring the dimensions guide patient and family

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Inspire

American Academy of Ambulatory Care Nursing

(AAACN)

Competencies for Care Coordination

and Transition Management

Haas, S., Swan, B.A., & Haynes, T. (2013). Developing ambulatory care registered nurse competencies for care coordination and transition

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Inspire

American Academy of Nursing (AAN) American Nurses Association (ANA)

Delineating RNs essential roles in Patient care coordination.

ANA Webinar

Navigating New Frontiers:

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