pre meeting interactive learning carousel may-21_2015_six per slide
TRANSCRIPT
Station 1: Why are you here today?
I am here because I care about what I do and how I do it in transitioning individuals into community living.
To learn about resources for transitions
To learn more resources that are available for
community transitions
Planning to implement a lot with COPD (high risks + readmission). New ideas?
To learn and reflect-what do other people do that works well and I could do also?
To gain knowledge about transition resources avail
Station 1: Why are you here today?
To learn + exchange ideas to share what tools we have + hopefully learn more to become better with transitioning people
Exchange ideasDevelop and/or learn innovative strategies. How are others doing it
Learn how to better coordinate successful transitions from SNF’s
To networkTo increase my knowledge of resources for transitioning from program to another
Station 1: Why are you here today?
Network and learn more about community
Hear more about resources program in NC
To learn as much as possible to better asst my patients
To better learn a cohesive path to ensure smoother transitions for care & to learn!
To gain more insight on the transition process, also possibly network with other transition team leaders, to also take back some info to my facility to better meet the needs of population I serve (complex patients)
To learn how to overcome obstacles in transition process
Station 1: Why are you here today?
1. Interested in topics, i.e. Job/work 2. Increase referrals... for MFP
To learn more about transition planning, things I don’t already know, and learn from my peers
To become more effective as a transition coordinator
To increase my knowledge of comm resources
To hopefully learn ways/techniques to assist me when pts transition from one healthcare setting to the next
To learn more about resources available in the community for my residents who are discharging
Station 1: Why are you here today?
To learn & share strategies that will allow for smooth transitions to home & reduce readmissions
Additional info on transition
How to better assess which patients are likely to successfully transition into the community
To learn new skills, to present, and meet others that have a shared interest in helping individuals with I/DD and Autism
To gain the skills necessary to lead individuals & other professionals into successful transitions
Learn and grow
Station 1: Why are you here today?
To learn how D.C. Senior Services can play a role
in transitions
To learn resources to better assist community transitions
Learn, Share, Act
To gain better knowledge & resources for transitions
To learn as much about the MFP process, to be better at my job
To learn more info about the transition process
Station 1: Why are you here today?
Interested in being part of conversation to address needs of folk transition
Learn about more resources for people who are transitioning, learn how to engage family & guardians
Try to update peers of incredible fast pace of hospital difficulty of stress
To hopefully bring back some good community resources that will help myself and my co-workers in our discharge planning
Learn how to break down barriers w/ transitions process
To grow professionally, to learn, to network
Station 1: Why are you here today?
Learn others’ golden nuggets about best person-centered practices and applied to quality transitions into real community life
To put things in perspective
The potential to affect change
To be able to enhance my knowledge, improve our transitions care program, to expand in all care settings
Station 2: What facilitates (supports) transition efforts?
Communities Coordination Supporting the person’s goals
Getting input from the person who is transitioning
Resources & referrals
What team members can do & what their agency
can provide
Station 2: What facilitates (supports) transition efforts?
Transition coordinator/agency developing strong collaborative partnership
Effective communication b/w community base providers & hospitals Realistic expectations
Knowledge of sustainable supports
Collaborative work among agencies
Community effort-everyone on the same page working toward the same goal
Station 2: What facilitates (supports) transition efforts?
Staying person-centered Good action plan & someone they can call on
Open-minded, not imposing your belief values
Natural supports & invested team members Supportive family
Primary care
Station 2: What facilitates (supports) transition efforts?
CommunicationAdministrations that understand the process
A team of people who we can rely on! As a transition coordinator, I know some things- but need a good tam/network to ask questions
Team work among all players
Relationship and rapport with individual Good communication
between programs
Station 2: What facilitates (supports) transition efforts?
Person being open to next level of care
Other professionals understanding the
program (MFP, PACE) The needs of the person needing transition care
A positive attitude from all team members so that the person can be successful
Teamwork and open communication
The attitudes of the care worker & the individual
transitioning & knowledge of care
worker to resources available
Station 2: What facilitates (supports) transition efforts?
Addressing barriersUse of evidenced-based
practices across the continuum
Referrals & coordinating with resources for a successful transition
Good communication, available resources, patient/family buy-in/support
Involvement of durable medical providers, such as respiratory post D/C
Strong support system “family, church, friends, neighbors”
Station 2: What facilitates (supports) transition efforts?
Natural support, good plan developed with individual, monitoring and .... addressing barriers
Provider agencies, developmental centers & MCOs
Trust & relation support
Collaboration among supports
People who are willing to take risks!
Being a knowledgeable guide
Station 2: What facilitates (supports) transition efforts?
Positive attitude, wanting to learn, avail resources, be realistic and honest
Consideration of the whole person and identifying best and worst scenarios and planning for the most support possible
Good action plan & someone they can call on
Station 3: What are the barriers (hinders) to transition efforts?
Lack of staff with base community resources
Issues with school systems not being tolerant
No placements available for adults/children that can meet needs. Providers saying they have availability, capability, experience but don’t
Lack of knowledge of what each level of care can provide among providers
Lack of communication or warm hand off to community-based providers, hospitalization
Occasional lack of transparency
Station 3: What are the barriers (hinders) to transition efforts?
Political will to remove all the barriers
Lack of knowledge on possible purchasing a home
Need for additional technology rest assured
Money within communities to provide resources & FTEs
Not identifying needs prior to discharge, i.e. equipment, financial capability to pay for medicines etc.
No funds available within the time needed for services trying to access
Station 3: What are the barriers (hinders) to transition efforts?
Lack of resources
Willingness of the person to apply for
resources
Lack of resources, “transportation”,
housing
Medicaid deductible
Categories of support: there are always people who fall thru the cracks, don’t qualify-we need to be creative about making sure they have needs met!
Limited ICF (intermediate care facilit
y) vacancies
Station 3: What are the barriers (hinders) to transition efforts?
No insurance, self payNo primary care giver but trying to figure out how to access their rights
Lack of family/community
support
Low incomeLimited resources
Housing/criminal background before
disability
Station 3: What are the barriers (hinders) to transition efforts?
Home repairs Knowledge of resources, i.e. Home mod, housing
Organizational policies & procedures
Organizational policies & procedures
Transitioning pts from home to SNF and
haven’t seen MD in months/years
Rural areas with limited resources especially
transportation
Station 3: What are the barriers (hinders) to transition efforts?
Rural areas (lack of resources) Communications, lack of
technology in home
Wait time-transition process takes too long and they get frustrated
Lack of housing/support systems
Unrealistic expectation of person, lack of acceptable understanding of medical needs
Lack of finances, community support, and options
Station 3: What are the barriers (hinders) to transition efforts?
Lack of community, family support
Hospital not aware of community partners (if
person doesn’t tell staff)
Patient + medical team not having same goals
Lack willing or capable caregivers
Lack of transportation On-going criminal activities
Station 3: What are the barriers (hinders) to transition efforts?
Expectation from everyone involved
Not enough resources in my area, medics/Medicaid restrictions guidelines
Funding, lack of appropriate services, lack of insight, and motivation
Time frame for application approve assessment
Affordable/accessible housing, community-based personal assistant services, policy that limits individual choice
ACTT drift of mission over the years trying to partner, equip, encourage staff to join our “mission”
Station 3: What are the barriers (hinders) to transition efforts?
Station 4: Emerging principles
Work yourself out of a job Be creative-outside box Flexible
Crisis planning
If nursing home patient came from home that
was not safe/cannot go back
Optimistically honest
Station 4: Emerging principles
Resonates most, being optimistically honest-if people, family know, it’s better for them to plan
Assessment-building relationship
Optimistic honesty + education
Not chaotic or sluggish, keeping momentum going hard
Center is person & family
Participant in the middle (harder than it looks)
Station 4: Emerging principles
Individual is guiding the goals Empowering person to
take responsibility
Making LTC facilities know about transitions opportunities-for public too
Community-based services, housing, transportation, individual choice
Holistic perspective Put everything in place
Station 4: Emerging principles
Warm hand offs Collaborating with others
Relationship building with participant—family
Communication & other systems SS/DSS/AEC, etc.
Need to know continuity of resource knowledge & communication
Don’t have to be an expert in everything
Station 4: Emerging principles
TeamworkCommunication, funds, step out of the box, ...
There should be conversations with guardians/people about transition prior to making application. Sometimes when I come to initial meetings-the guardian/person has no idea why I am there and I have to awkwardly explain. There should be several initial conversations with the team prior to beginning the MFP process.
Tracking outcomes to provide evidence-based practices