MA STAAR Fall Learning Session Ensuring Post-Hospital Care

Follow-up

2:45-4:00PM Breakout St. Anne’s Hospital, MetroWest Medical Center

Peg Bradke and Kate Bones

I. Perform Enhanced Admission Assessment of Post-Hospital NeedsII. Provide Effective Teaching and Facilitate Enhanced LearningIII. Ensure Post-Hospital Care Follow-UpA. Reassess the patient’s medical and social risk for readmission. B. Prior to discharge:

• Schedule timely follow-up care and • Initiate clinical and social services summarized from the

assessment of post-hospital needs.

IV. Provide Real-Time Handover CommunicationA. Give patient and family members a patient-friendly post-hospital

care plan which includes a clear medication list.B. Provide customized, real-time critical information to next clinical

care provider(s). C. For high-risk patients, a clinician calls the individual(s) listed as the

patient’s next clinical care provider(s) to discuss the patient’s status and plan of care.

Creating an Ideal Transition Home

How do we effectively and efficiently act on our assessment of post-discharge needs

and collaborate with patients, their families, and the community (healthcare and

support systems) to transition.

or

IHI’s Roadmap for Improving Transitions and Reducing Avoidable Rehospitalizations

* Additional Costs for these Services

Improved Transitionsand Coordination of Care

Reduction in Avoidable Rehospitalizations

Patient and Family Engagement

Cross-Continuum Team Collaboration

Evidence-based Care in All Clinical Settings

Health Information Exchange and Shared Care Plans

Requested Coordinating Activities and Communications

• What information does the receiver need from hospitals…

• What information the community providers can provide to the hospitals…

Potential Next Steps• Practice(s) and/or their representatives become part of the hospital’s

STAAR CCT.• Hospital STAAR CCT chair appoint a contact who will work with the

practices or community provider and report back to the CCT regularly.• At a CCT meeting (including the practices and/or their representatives)

the CCT reviews a patient case where lack of coordination between the hospital and practice had an impact on patient care.

• Based on the patient case, the practice(s) and/or their representatives and the hospital CCT select 2-3 areas to begin testing how to best coordinate activities and communications.

• Community providers and the hospital contact develop a work plan for learning from testing and addressing all the agreed upon change areas.

Discussion

• Who is working with practices and clinics now?

• How are you cooperating to reduce risk for readmission?

Social Risk Assessment• Besides Meals on Wheels, what other social

service and community resources do you refer your patients to?

• Does anyone have a useful check list for identifying social risks (lives alone, little involvement of others in care, anxiety and/or depression, quality of life, and functional status, along with socioeconomic status)?

Social Support

• Social support is broadly defined as the existence or availability of people on whom one can rely; people who let one know that they are cared about, valued, and loved. Lack of social support is associated with increased morbidity and mortality in patients with ischemic heart disease." (Vaglio, Conrad,  et al Testing the performance of the ENRICHD Social Support Instrument.  Health Qual Life Outcomes. 2004; 2: 24.) 

ENRICHD Social Support Instrument 

"The results also provide conceptual insight into the nature of social support. The majority of questions on the ESSI consider general feelings about being loved and valued rather than instrumental types of support. This supports the theory that social support is not a tally of actual supportive "services" rendered, but rather a patient's belief that others care about them and are available if needed."

Health Literacy, Medication Adherence and Social Support

"having a trusted confidant was the only type of social support associated with better medication adherence for limited-literacy patients” (Johnson, Jacobson et al.  Does social support help limited-literacy patients with medication adherence?: A mixed methods study of patients in the Pharmacy Intervention for Limited Literacy (PILL) Study.)

Discussion

• How might we expand social support beyond the technical to include assessing for someone who cares about me?

• How might this help us? Help patients?

What is one new thing you learned

today that you would like to test?