wentworth-douglass hospital story kimberly chapman, rn, ms, cnl, pccn discharge advocate for project...
TRANSCRIPT
Wentworth-Douglass Hospital Story
Kimberly Chapman, RN, MS, CNL, PCCNDischarge Advocate for Project REDWentworth-Douglass HospitalDover, NH
Monique Drouin, RNRN Care ManagerStrafford Medical AssociatesWentworth Health PartnersDover, NH
About Us Wentworth-Douglass Hospital
• Dover, NH• New Garrison Wing• Not-for-profit charitable organization
accredited by the Joint Commission on Accreditation of Healthcare Organizations.
• U.S. News Ranks WDH in the top 100 Best Hospitals
• Joint Commission Certified Primary Stroke Center
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What Did We Test?
• Project RED• Discharge Advocate• 11 Components
1. Medication reconciliation
2. Reconcile discharge plan with national guidelines 3. Follow-up appointments 4. Outstanding tests 5. Post-discharge services 6. Written discharge plan 7. What to do if problem arises 8. Patient education 9. Assess patient understanding10. Discharge summary sent to PCP11. Telephone reinforcement 3
What Have We Learned So Far?
• After Hospital Care Plan is essential• Communication is key!• Patients like seeing a consistent person
throughout the hospital stay• Patient Engagement
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What Barriers Did We Encounter?
• IT issues: – AHCP (time consuming manual data entry, no interface)– Notification of pilot patients
• After Hours Coverage: weekends, evenings, holidays and vacations
• Contacting patients after discharge• Scheduling hospital follow-up appointment
within 7 days
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How Did We Overcome These Barriers?
• Demo of Engineered Care Software to create the After Hospital Care Plan
• Connecting with other hospitals who use our EMR system
• Planning proposal for budgeted position • Creating more ‘hospital follow-up’
appointment slots.
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How Are We Doing Now?
• Process metrics:- Average time to notify Discharge Advocate about new
admission- Average time from admission to first patient visit- Percent of patients whose PCP office care manager was
notified within 1 day of discharge- Percent of follow-up phone calls made within 2 days of
discharge.
• Outcome metrics:- Average LOS- 30 day unplanned readmission rate
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What Can Others Learn From Our Journey?
• We are still learning too!• Coordinated effort between inpatient and
outpatient services• Importance of follow-up call
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Do Not Try This At Home (Suggestions for What Not to Do…)
• Don’t start too big!• Don’t minimize the work associated with
creating the After Hospital Care Plan
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Teach Back
• Summary• Next Tests of Change (TOC) • Questions?