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Bcp inservice outreach linked in


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Bcp inservice outreach linked in

  1. 1. The Role of Private Duty Home Care in Reducing Hospital Readmissions & Enhancing Quality Of LifeTaking Private Duty Home Care to a Whole New Level Hospital Assisted Nurse Discharge Service (HANDS) and BrightStar Clinical Pathways
  2. 2. The Opportunity • Hospital/Health System As part of the PatientProtection & Affordable data will be scrutinized at a Care Act (PPACA), there number of levels andare a number of changes failure to achieve certain that will impact reimbursement to national CMS benchmarks hospitals and other will result in healthcare systems – Financial Penalties • Excessive Readmissions National efforts are underway to reduce – Less Robust Rewards potentially preventable • Poor Customer Satisfactionhospital readmissions and optimize the patient • Poor Outcomes of Care experience
  3. 3. *Centers for Medicare & MedicaidServices, Public Affairs, April 2009 Medicare data shows that nearly 1 in 5 patients who leave the hospital are readmitted within the next month and that more than 75% of these Healthcare readmissions are preventable* systems need to look for new solutions since Research has demonstrated that many existing of the return trips can be prevented approaches are with an in-home care program not solving the that includes proper education and problem. supervision.
  4. 4. Top Reasons for 30-day hospital readmissions: Failure to make follow-up appointments Lack of communication Failure to understand medication management Absence of in-home support Non-adherence to lifestyle recommendations Failure to understand and actively participate in the management of their chronic disease
  5. 5. At BrightStar we utilize a Best Practice approach to care following theNational Quality Standards of The Joint Commission
  6. 6. Cutting Edge Clinical Programs The Framework:Making More Possible BrightStarWe are companions on LifeCarethe healthcare journey BrightStar our clients take. KidCare Clinical Pathways℠ Staffing BrightStar’s clinical programs allow us to HANDSpartner with the client, their family and their Person-Centered Care healthcare team to Clinical Expertiseenhance quality of life National Quality Standards and improve care outcomes.
  7. 7. BrightStar’s Clinical Pathways ℠ and HANDSProgram was inspired by nationally recognized care transition programs: Coleman Care Transition Intervention Program which reduced hospital readmissions by 50% at 30, 60 and 90 days
  8. 8. HANDS is a transitional care program focused on a safe transition home After leaving the hospital it is important that the patient have a direct link to an accessible care provider. HANDS provides that link, bridging the transition to home and addressing issues and questions that arise. Medicare agencies may not be able to be there within the 1st - 24 hours and sometimes not for 2-4 days.
  9. 9. • BrightStar’s Hospital Accelerated Nurse Discharge Service (HANDS) is a transitional care program to facilitate a safe discharge home. – It is ideally the beginning of a journey we take with the client and their healthcare team. HANDS: • It begins at time of discharge and continues for a minimum of 24 hours – critical transition time forWhat is it to re-engagement in the home setting. • A visit by our Registered Nurse Care Our Manager is the cornerstone of the program – Assessment, Medication Reconciliation, Disease Partners? State Education w/attention to Red Flag Symptoms • Person-centered services performed by our CNA – Transportation from hospital to home, Home Safety Check, Light Housekeeping, Retrieval of Simple Supplies (medications, groceries, etc), Light Meal Prep, Transition Check List which includes phone calls to loved ones, arranging/confirming follow-up appointment with discharging physician
  10. 10. • HANDS Basic – 3 hours CNA timeHANDS Basic – 1 RN Home Visit w/i 4-8 hours of Services hospital discharge • HANDS Plus – Everything included above – Pre-discharge RN Visit at hospital (meet & greet, chart review, discharge instructions, etc) – 1 additional RN visit – 24/7 RN phone call availability forHANDS Plus 30 days Services – Detailed medication instruction/med set-up if indicated
  11. 11. BrightStar Clinical PathwaysEmpowering individuals with chronic illness through our best practice approach
  12. 12. Simply put…BrightStar Clinical Pathways ℠ is a –patient centered –condition-specific –transitional care programFocused on –reducing negative outcomes –optimizing quality of life
  13. 13. BrightStar Clinical Pathways SM Patient Centered Evidence-based Condition-specific Best practice approach Time-limited (4 wks) RN Clinical Pathway Coordinator Specially Trained CNAs
  14. 14. BrightStar Clinical Pathways SM Heart failure COPD Pneumonia Acute MI Delirium & Dementia Diabetes Falls with Fracture
  15. 15. BrightStar Clinical Pathways℠ Materials
  16. 16. BrightStar Clinical Pathways ℠ : Essentials Package 4 RN CPC Visits, 8 RN CPC Virtual Visits, 13 Specialty CNA Visits Week 1 Week 2 Week 3 Week 4 TTL RN Visit X X X X 4 RN Phone Call X X X X X X X X 8 CNA/HHA Visit X X X X X X X X X X X X X 13 25Each face to face visit is a 2 hour condition-specific person-centered interaction focused on empowering the client as wellas symptom surveillance
  17. 17. BrightStar Clinical Pathways ℠ MS DRGs and Frailty FactorsMS DRG MCC *Frailty Factors • Mult Diagnoses Essentials • Mult. Medications MS DRG CC Plus • ADL/IADL Deficits • Unintentional Wt Loss • Limited Support MS DRG Essentials Frailty Factors*
  18. 18. BrightStar Clinical Pathways ℠ : Essentials Plus Package 5 RN CPC Visits, 13 RN CPC Virtual Visits, 17 Specialty CNA Visits Week 1 Week 2 Week 3 Week 4 TTL RN Visit X X X X X 5 RN Phone Call X X X X X X X X X X X X X 13 CNA/HHA Visit X X X X X X X X X X X X X X X X X 17 35Each face to face visit is a 2 hour condition-specific person-centered interaction focused on empowering the client as wellas symptom surveillance
  19. 19. Other Essential Elements ofBrightStar Clinical Pathways℠ – Care Together • Web based communication and calendar tool for the client and their formal and informal care team; also promotes the self- management of chronic illness Building a – PressGaney/Patient Impact • National Patient Satisfaction Survey Platform of comparable to what many hospitals utilize Clinical – We hold ourselves to a high service standard Excellence – 9 out of 10 clients would refer us to a friend – ABS 2.0 • Data tracking of diagnosis, recent hospitalizations, reasons for admission/readmission; • Staff assignment
  20. 20. ℠Three key ways CareTogether enhances BCPs for clients & their families:1. Condition specificeducational materials, care Families using with physicians and casetools, resources managers can enhance communication and understanding and adherence!
  21. 21. ℠Three key ways CareTogether enhances BCPs for clients & their families: 3. Keeping the family involved and updated is key part of 2. Calendar linked with ABS family and friends supporting shows client + Care Team visit the care and “better choices” of dates, times, name and more the Pathways program
  22. 22. HCAHPS vs BrightStar Press Ganey Survey %20HCAHPS%20Mail%20Survey%20Materials%20(English)%202-16-2011.pdf Discharge Plan?Which questions match between HCAHPS & Press Ganey? Which questions illustrate opportunities for BrightStar to help?
  23. 23. BrightStar Clinical Pathways ℠ Foundational Concepts• Person Centered – The individual is more than the sum of their parts (or their diseases and medications)• Patient Empowerment with Self Management of Chronic Disease• BrightStar Clinical Pathway℠ Team Leader – Together – Everyone – Achieves – More
  24. 24. Key BrightStar Clinical Pathways℠ Coordinator Goals• Motivate Clients – To become as independent as possible in monitoring and maintaining their own health status• Provide Clients with the knowledge and skills – To make informed decisions about their healthcare and quality of life• Reduce negative outcomes – Hospitalizations, Readmissions, Urgent Care Visits ,ER Visits, Falls, Med Errors, etc• Maintain active communication – BrightStar Clinical Pathway Team, Client’s Family and Physician, Other Healthcare Providers
  25. 25. HF Visit Details: RN & CNA
  26. 26. HF Knowledge Guidebook
  27. 27. HF Red Flag Alert
  28. 28. HF Symptom Tracker
  29. 29. Benefit to Patient: Continuous care for better outcomes RN education Earlier Discharge Reduce risk of falls relationship One on one help and Additional resourcesImproved medication guidance in the home to provide care, management from specially transportation, RX trained CNAs pick up, cleaning, etc Stay out the of hospital and the ER
  30. 30. What this program will mean to Healthcare Systems & Providers: Better Patient Outcomes Improve Efficiencies Improved Identify high-risk patients Communication Complements patient and and target specific family preparation forImprove flow of information interventions to mitigate discharge. Ensure a timely,between hospital, their risks for adverse efficient and safe0utpatient physicians and events. With timely post discharge and transitionprovider. discharge in-home care to home. management and follow up. Better ImageImprove patient and public Reduce likelihood ofperception of care and result inhigher satisfaction scores. potentiallyPromote customer loyalty &confidence in St. Marys and preventable andenhance patient overall costly readmissionsexperience.
  31. 31. Why BrightStar? Our Difference: Joint Commission Accreditation  Commitment to RN oversight Fully Licensed by the  Person centered approach Press Ganey satisfaction survey  CareTogether® Licensed and insured for transport  Flexible & responsive RN DON trains & competency tests  Highly qualified and specially trained staff all CNAs  Stringent screening and employment All patients receive in-home risk practices assessment to help reduce falls  HANDS Continuity of care and care collaboration  BrightStar Clinical Pathways Ongoing services to maintain safety  Locally owned & operated and success
  32. 32. Ask Me How We CanMake More Possible For You! 805.358.6022