Transition of Patient from Hospital to Home/Next Level of Care

Caring Advocacy: Transition of Patients from Hospital to Home/Next Level of CareLynn Eubanks, RN, BSN, Patient Care Coordinator SFOMargaret G. Williams, RN COCSD SFO

San Francisco Kaiser Permanente – 2425 Geary Blvd., San Francisco, CA 94115

Caring Advocacy & Early Planning for After-hospital Care

• Focus on “Caring Science of Nursing” to increase patient’s understanding of transition from hospital

• PCC Team assesses after-hospital needs – the next Level of Care (LOC)

• PCC’s & Multidisciplinary team assists patient/family in planning care & accessing Continuum resources

Patient Care Coordinator (PCC )Team

• Coordinates patient transition from hospital

• Manages clinical utilization with InterQual – medical necessity

• Partners with Multidisciplinary Team (physicians, RN’s, SW’s, PT’s, pharmacy, etc.)

• Manages transition care

4 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.April 9, 2023

Why focus on Transitions now? Impact to 2012 World Class Hospital Goals

Value ~ Caring Advocacy Embraces

• Right Venue of Care• Timely Patient Care• Coordinated Care

Implementing Caring Processes Collaboration Is A Process

• Daily Bed Meeting

• Scripted communication between Pt. & family/Multidisciplinary team members

• Frequent dialogue with Nursing Managers, Bedside RN’s

• PCC Team works with physicians/PCS partners

• “Discharge Planning/Admission Assessment” Form

• Early planning reveals barriers to discharge & facilitates smooth transition

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| © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.

K-SFO BED MEETING


#1 Admission Assessment = Good Discharge Planning

Review all inpatient admissions to SFO Interview/assess patient/family within 1 day of

admission ID crucial points of discharge planning & partner

with patients/families to ID and assess needs, resources, gaps (Human Needs Assistance)

Document Anticipated Discharge Disposition (ADD) Document Expected Date of Discharge (EDD)

Starting with our initial interview we focus on

both the “Cared-for” and the “Care-givers”


#2 “Going Home” Assessment Tool & Script

Introduced as a training tool in 2011

Process now embedded in daily PCC practice

Engages patient/family in planning for transition

Develops Helping-Trust Relationship with patient/family

White Board in patient room – ADD + EDD prepares patient/family/hospital care team


#3 How We Help

We are the “Care Coordination Navigators”

Early/frequent assessment

Identify barriers to discharge

Streamline documentation & communication

Coordinate intra-departmental participation

We build patient/family confidence, decrease discharge fatigue & reduce last-day hassle

Results

• Multidisciplinary Team growth

• Increased Multidisciplinary Team communication

• Increased Patient Satisfaction

• Decreased Patient Day Rate (PDR)


Measuring Success: HCAHPS

1. 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?

2. During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital?

Excludes OB/Pedi

HCAHPS Discharge Information Composite Results

83

84

85

86

87

88

89

90

91

92

Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12

% T

op B

ox


Lessons Learned• Start transition planning within 1 day

of admission• Communicate via authentic

interactions verbally and in writing with patient and entire care team

• Document in HC: “Care Coordination Navigator”

• Execute safe discharge plan


Follow through ~ ~ ~ Follow Heart

Caring Advocacy provides the best discharge outcomes possible

Transition of Patient from Hospital to Home/Next Level of Care

Health & Medicine

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