Inspiring Improvement:Creating an Ideal Transition Home       Susan Seeman, Director of Strategic Initiatives            G...
VCH – Vancouver’s True North Goals &                   Strategic PrioritiesBreakthrough StrategyMatching capacity &     de...
Ideal Transition Home Initiative                              Problem Statement• Our readmission rates have increased  fro...
Ideal Transition Home initiative                                  Goals•   To improve the patient and family    experience...
Creating an Ideal Transition Home Process   Enhanced                                     Real-time   Admission            ...
Ideal Transition Home Initiative Update         Phase 1- Implemented on 250 Medicine beds    Within 48 hours of admission:...
Ideal Transition Home Initiative Update  Phase 1- Implemented on 250 Medicine beds                       Upon discharge:  ...
8
Ideal Transition Home – Phase 2        Enhance Coaching, Education and          Support for Self ManagementIHI Recommendat...
Coaching and Education Focus                                           Primary &                                         H...
MyChronicDisease Action            Chronic Disease Action Plan  Plan    Teach     back                                    ...
My Discharge Plan                    Next Page
My Discharge Prescription                            13
Get Well Soon                14
Getting to Know the ITH Population                                 Patient Risk Level                                 Low ...
How are we doing?                  Readmissions as a % of Total Discharges from iCare Units                     Readmissio...
Feedback from GPs                        Preliminary Results:        Primary Care Physician Interview: Ideal Transition Ho...
Feedback from GPs                    Preliminary Results:    Primary Care Physician Interview: Ideal Transition Home      ...
Lessons Learned• Community Care services need faster response times to  receive the demand from acute• Community GPs reall...
Patient ExperienceFrom Mrs. P. (61 y.o. female, admitted to VGH 10  times in 2011 and twice in 2012, multiple chronic  hea...
Team Experience“The biggest difference I have seen since the  implementation of the ITH initiative is the  seamless transi...
Appendix           22
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GPHospitalNotificationForm               28
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B4 Susan Seeman - Inspiring Improvement : Creating an Ideal Transition Home

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B4 Susan Seeman - Inspiring Improvement : Creating an Ideal Transition Home

  1. 1. Inspiring Improvement:Creating an Ideal Transition Home Susan Seeman, Director of Strategic Initiatives Goldie Luong, Director, Special Projects Vancouver Acute Services, VGH 1
  2. 2. VCH – Vancouver’s True North Goals & Strategic PrioritiesBreakthrough StrategyMatching capacity & demand How do we match capacity to demand to provide best care? Reducing Readmissions How do we reduce readmissions? Ideal Transition Home Initiative 2
  3. 3. Ideal Transition Home Initiative Problem Statement• Our readmission rates have increased from 8.9%(FY08/09) to 9.7%(FY10/11)• Implemented iCARE on Medicine Units which identified: o a lack of standard processes associated with discharge/transition planning o an opportunity to improve linkages with community partners to support the plan of care after discharge o sporadic communication and engagement with family physicians when their patients were admitted coupled with minimal involvement in discharge plan 3
  4. 4. Ideal Transition Home initiative Goals• To improve the patient and family experience and provide quality care by implementing 4 key recommendations from the Institute for Healthcare Improvement (IHI).• Areas of focus: o Improve core discharge planning and transition processes out of acute care o Improve transitions and care coordination to primary and community care providers o Enhance patient coaching, education, Some members of our ITH team and support for self management representing allied health, nursing, transition services, physicians and care management. 4
  5. 5. Creating an Ideal Transition Home Process Enhanced Real-time Admission Effective Patient and Post Hospital Assessment Teaching and Family-Centred Care Follow for Post Enhanced Hospital Learning Handoff Up Communication Needs Process Tools1. iCare Admission 1. Chronic DiseaseAssessment Action Plans 1. Standardized2. Readmit Risk 2. Teach Back patient transition 1. Book follow upScore methodology (discharge) appointments3. Readmit Risk 3. Acute to instructions-My 2. Follow up callFactors/Mitigation community Discharge Plan4. Readmit Interview learning plans Real-time Quality Measures% of patients with % of patients who % of patients with % of time transitionrisk assessments can teach back > scheduled follow up plan transferredcompleted within 48 two thirds of appts before with patienthours content taught discharge
  6. 6. Ideal Transition Home Initiative Update Phase 1- Implemented on 250 Medicine beds Within 48 hours of admission: Readmission Risk assessment score initiated (early identification of patients at moderate to high risk for readmission) Readmission Risk mitigation checklist initiated (standardized interventions) Hospitalization notice faxed to GP in community Referral sent to community for moderate and high risk clients 6
  7. 7. Ideal Transition Home Initiative Update Phase 1- Implemented on 250 Medicine beds Upon discharge:  My Discharge Plan completed and given to patient/family and faxed to community and community GP (discharge notification fax)  High risk patients - Follow up GP appointment made prior to discharge for 48 hours post discharge  Moderate risk patients - Follow up phone call to patient/family by Care Management Leader 48 hrs post discharge  Readmission interviews with patients and families 7
  8. 8. 8
  9. 9. Ideal Transition Home – Phase 2 Enhance Coaching, Education and Support for Self ManagementIHI Recommendations:• During the acute care hospitalization only essential education is recommended• Focus on key need-to-know points (not nice-to-know)• Emphasize what the patient should do, what action to take• Use Teach back to ensure learning 9
  10. 10. Coaching and Education Focus Primary & Home Care and Specialized Clinics Creating the Ideal Transition 10
  11. 11. MyChronicDisease Action Chronic Disease Action Plan Plan Teach back 11
  12. 12. My Discharge Plan Next Page
  13. 13. My Discharge Prescription 13
  14. 14. Get Well Soon 14
  15. 15. Getting to Know the ITH Population Patient Risk Level Low Moderate High• 302 Discharged Patients – 49 Low Risk Patients 33% 16% – 155 Moderate Risk Patients 51% – 98 High Risk Patients 15
  16. 16. How are we doing? Readmissions as a % of Total Discharges from iCare Units Readmission Rate Readmission (Pre Pull/Partial iCARE Impl) Readmission (Post Pull/Partial iCARE Impl) Readmission (Post IHT) CIHI Readmission Rate CIHI Readmission (Pre Pull/Partial iCARE Impl) CIHI Readmission (Post Pull/Partial iCARE Impl) CIHI Readmission (Post IHT)18% Pull Strategy / iCare ITH Partial iCARE Impl16%14%12%10%8%6%4% iCARE readmissions as a % of total discharges decreased 0.5% (0.9 beds per day) pre2% and post ITH implementation, which is 3.5% reduction; and it decreased 2.2% (3.9 beds per day) based on CIHI readmissions methodology (unplanned and related diagnose).0% Period
  17. 17. Feedback from GPs Preliminary Results: Primary Care Physician Interview: Ideal Transition Home Patients 90% 90% YES NO 90% 70% 30% 10% 10% 10%Notification of the Easy to find contact Clear about your role Easy for you/yourpatients admission information on in the patient’s office to see the TIMELY nursing or the MRP discharge patient urgently 17
  18. 18. Feedback from GPs Preliminary Results: Primary Care Physician Interview: Ideal Transition Home Patients YES NO 90% 90% 90% 80% 20% 10% 10% 10%Receive discharge Done anything Recommend this Other suggestionssummary in timely differently to notification process or observations manner improve the standard of care or make your participation easier 18
  19. 19. Lessons Learned• Community Care services need faster response times to receive the demand from acute• Community GPs really like the process, want this throughout the hospital• Unit audits show the importance of compliancy with process and standard work• Weekly pareto analysis determines themes and action plans for readmissions – Chronic Disease Action Plans 19
  20. 20. Patient ExperienceFrom Mrs. P. (61 y.o. female, admitted to VGH 10 times in 2011 and twice in 2012, multiple chronic health conditions) “After coming back again to VGH, it was nice tospeak with someone at the hospital who wasfamiliar with my story and who was going to try tohelp me to spend more time at home with mygrandchildren.” 20
  21. 21. Team Experience“The biggest difference I have seen since the implementation of the ITH initiative is the seamless transition from hospital to home. The focused education on My Discharge Plan and the increased communication at discharge with patients encourages them to be involved in their care. This initiative is truly demonstrating continuity of care.” –Denise Kendrick, OT 21
  22. 22. Appendix 22
  23. 23. Go Back
  24. 24. Go Back
  25. 25. Go Back
  26. 26. Next Page
  27. 27. Go Back
  28. 28. GPHospitalNotificationForm 28

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