Same Page Transitional Care: Creating a Template for Optimal Transitions

Organizations: Planetree
Principal Investigator: Michael Lepore, PhD

Always Event(s): Patients will always have the opportunity across healthcare settings to utilize a portable personal health record embedded with actionable patient-driven information, to ensure patients, their healthcare providers and their family members are on the same page with regard to the patient’s healthcare needs, priorities, and lifestyle.

Overview: The overarching goal of this low-cost initiative is to establish a template for the type of transitional care patients should always experience. Specific aims of this initiative include: (1) heightening patients’ and informal caregivers’ confidence in managing healthcare needs, (2) improving the quality of communication, coordination, and collaboration across care settings, and (3) reducing the frequency of unnecessary re-hospitalizations. To accomplish these aims Planetree has launched a multidimensional initiative involving implementation of a validated web-based patient self-assessment tool (How’s Your Health) that offers actionable information about what matters to patients, coordinated with a Care Partner program, wherein the patient and his/her informal (family/friend) caregivers are actively engaged in healthcare planning. Planetree will introduce this Same Page Transitional Care initiative in the context of four hospital and nursing home dyads who have already implemented elements of effective transitional care. All dyads belong to Planetree’s network of patient-centered healthcare organizations, and are therefore skilled and experienced in redesigning care processes with the patient at the center. Same Page Transitional Care is intended to assure that patients, their informal caregivers, and healthcare providers across settings, particularly hospitals and nursing homes, are on the ―same page with regard to patients’ health and healthcare needs, and that this ―page is grounded in patient-reported measures.

Care Partner Agreement

Care Partner Resources

Organization: Henry Ford Health System
Principal Investigator: Rhonna Shatz, DO

Always Event: Always screen patients 70 years and older for dementia as part of their annual primary care health exams.

Overview: This initiative will use a new Web-based cognitive assessment tool developed by the National Institutes of Health and modified for use at HFHS. Physicians will also utilize an NIH developed web-based smart survey tool to assess mood, behavior, daily living activities and review caregiver distress. Should the patient exhibit any signs of a neurological impairment following the cognitive screen, the doctor would initiate a full dementia assessment guided by EMR templates that can be downloaded or utilized and saved on-line as an office note. This program will involve training and preparing Primary Care Physicians (PCPs) within the hospital to observe senior adult patients during regular office visits to determine whether an undiagnosed neurological condition, especially Alzheimer’s disease, is present. While general practice physicians do regularly see a high proportion of senior adults, most do not typically have current expertise or knowledge in neurological medicine as it applies to age-related conditions. HFHS will conduct training to provide as many physicians as possible with techniques to quickly assess their senior patients. On-going training would then be held for newly hired doctors or as a refresher course for others. Should the patient exhibit any signs of a neurological impairment following the cognitive screen, the doctor would initiate a full dementia assessment guided by EMR templates which can be downloaded or utilized and saved on-line as an office note.

Henry Ford Health System Brain Health Brochure

Henry Ford Health System Eligibility Screening Tool

Children’s National Medical Center

Principal Investigator: Dale Coddington, MD, MA

Project Title: Caring for Children with Special Health Care Needs: An Online Medical Home Professionalism Curriculum for Pediatric Residents

Objective: This initiative is an experiential and online curriculum to help pediatric residents acquire the necessary knowledge, attitudes, and skills to deliver effective, patient‐centered care to children with special health care needs. This initiative will utilize direct experience in care delivery, individual and collective reflections, and collaboration with a broad health care and community team, all in the setting of residency continuity clinic experience. A component of this initiative is for residents to engage in reflective blogging with feedback from faculty and peers as an innovative method to learn professionalism in the context of caring for children with special healthcare needs in resident continuity clinics. The Always Event will be that, at the close of each clinical encounter, the physician and patient/family agree on next steps and on the specific responsibilities of the physician and the patient/family.

What is reflective blogging?

Pre-test Experience Survey

Modules: Caring with Children with Special Health Care Needs

A Conversation with Janet Parkosewich, DNSc, RN, CCRN, FAHA:
Premature Life Transitions program at Yale-New Haven Hospital

Janet Parkosewich is the principal investigator for the Premature Life Transitions project, which supports families in the Yale-New Haven Hospital’s Newborn Special Care Unit through the transition from curative care to palliative care, infant demise, and bereavement.  Janet describes how this project has not only improved care for patients and families, but has created an opportunity for two dedicated staff nurses, Julia Bishop-Hahlo, RN, BSN and Laurie Jonason, RN, BSNC, to translate their passion into leadership and action.

Your project relates to an intensely emotional experience, not only for families, but for staff.  How do you support staff members in learning not only how to support families, but how to care for themselves while providing palliative care for an infant and coping with infant demise? 

As part of this project, we asked staff to complete an end of life bereavement care survey.  We discovered that many of the staff members did not feel comfortable with the responsibility of caring for a dying infant and supporting families through that process.  We are building a select cadre of Transitions mentor nurses who can support other staff through this experience.  We are building staff skills, providing training, and implementing a step by step guide and checklist that walks staff through every step of the process.  In general, hospitals don’t do a lot to support staff through these events, but we know that this is a loss for staff too.  There is sometimes a perception that when an infant’s life support system is withdrawn, the nurse can take another baby right away because “you’re not doing anything.”  The nurses need time to care for the family and to grieve themselves.  Many times they have cared for these babies for weeks or months and have gotten to know the baby and the family well.  We need to support them.

What have you learned from the parents involved in this program? 

It is important to make sure we focus on what families themselves say they want and not what we think they need.  We are working closely with the Newborn Special Care Unit Aadvisory Committee and the parents on that committee have validated that this project is the right thing to do.  The parents on the committee represent a variety of perspectives and experiences, from infants that have died to infants that have been in special care, gone home and are thriving.  For all families, it is an emotionally charged situation.  What we say and do has a lasting impact.  One of the parents expressed it this way, “Do clinicians realize that we will never forget their names, their faces, and what they said to us about our dying child?”  We have used these words and other parent perspectives to reinforce the importance of the program to staff.   Less than humane interactions, such as “kidneys down, game over” are not acceptable.  Families will remember those words forever.  We also have learned how to have different types of conversations.  For example, in family meetings, we ask about the family’s goals instead of just giving the family information.  This dialogue brings everyone onto the same team.

Many organizations are interested in starting their own Always Events projects and could learn from your experience. What would you say are the secrets to your success? 

There are several factors that have been essential to our success:

The role of frontline leaders can’t be underestimated.  For families to receive the level of care we want, we have to give staff nurses these skills and experiences.  Often projects such as this involve nurse educators, but this project is being run by frontline staff.  The project has helped Julia and Laurie to flourish as leaders.  They are doing something they are passionate about and are being given dedicated time in the schedule to do it.  The Magnet program requires the involvement of frontline staff in improvement work and this project demonstrates the powerful impact that frontline nurses can have.

What’s next?

We are finishing our behavioral observations and will soon start with our educational intervention.  The Yale-New Haven Hospital pediatric intensive care unit will be joining the program and we also are expanding to other hospitals in the health system.  I am grateful to the Picker Institute for helping me realize my dreams.  This program has enriched my life. 

Patients and Families Improving Hospital Discharge

Health Care For All
Patients and Families Improving Hospital Discharge
Principal Investigator:Deborah Wachenheim

Health Care For All (HCFA) has joined together with the Massachusetts Coalition for the Prevention of Medical Errors (MA Coalition) to bring the patient and family voice into improving the hospital discharge process in order to decrease preventable readmissions and improve health and quality of life postdischarge. The project will result in a process where those being discharged (and their caregivers) and those managing the discharge have a full and shared understanding of the patients’ needs, abilities and access to assistance post-discharge. As a result, the capacity of Massachusetts’ hospitals to listen to consumers will increase, as will the level of consumer engagement with hospitals as they work together to design a consumer-centered discharge process. This project will: 

• Facilitate smooth discharges from hospitals to home;
• Improve the health care delivery system by reducing the number of preventable readmissions;
• Increase understanding of the concerns of patients and families by opening channels of dialogue on the topic of discharges through the hospital PFAC and patient and family involvement in the STAAR team improvements;
• Encourage the adoption of practical changes needed to facilitate a more patient-centered approach by developing best practices for the discharge process in response to the needs of patients and caregivers; and
• Improve the communication between patients and providers by offering models of effective listening and responsiveness to meet the needs of patients and families

Health Care For All Strategies for Improving Hospital Discharge

Riverside Methodist Hospital
Teaching Disclosure: A Patient-Centered Simulation Training for the Crucial Conversation
Principal Investigator:

The primary aim of this project is to improve residents’ ability to disclose medical errors. Disclosure, the process of bringing to light an unintended outcome, is essential to the nature of the patient-physician relationship. In this project, we are using simulated patient encounters, on-line teaching, self-assessment, and observer assessment to introduce the learners to proper disclosure.

By teaching residents the proper way to disclose medical errors in a simulated situation, we hope to improve their ability to do so when errors happen in clinical situations. Many barriers to successful disclosure exist. These may include communication deficits, fear of malpractice litigation, and difficulty in admitting to mistakes. Disclosure is inherently a difficult and stressful process, perhaps particularly in the young physician. During this simulation, the resident will be able practice disclosure in a safe and supportive environment. All fifty-six of the post-graduate year one (PGY1) residents at Riverside Methodist Hospital participated in a simulation centered on disclosing a medical error to a patient’s family member. The patient, in the scenario, was inadvertently given an overdose of a narcotic, leading to change in status and transfer to an intensive care unit. This is a realistic scenario that allowed the project team to teach and reinforce critical parts of disclosure, such as, clearly explaining the situation, expressing regret, and speaking to what will be done to prevent such an error in the future. Each resident participated in the simulation twice. In the intervening time, each PGY1 completed an on-line teaching module about disclosure.

The project team used a number of tools to evaluate the residents. Each learner completed self-assessments before and after the two simulations. The residents were also formally evaluated by faculty members and the standardized patients. This 360°-evaluation allowed residents to improve knowledge about the process of disclosure, as well as improve communication surrounding the acknowledgement of mistakes and providing an apology for medical errors.

Teaching Disclosure Simulation Development Form

Teaching Disclosure Simulation Flowsheet

Resident Pre-scenario Knowledge Assessment

Resident Self-Assessment Tool

Faculty Assessment Tool

Standardized Patient Assessment Tool

Outside Faculty Assessment Tool

University of Chicago: EPOCH- Engineering Patient Oriented Clinic Handoffs

University of Chicago
EPOCH: Engineering Patient Oriented Clinic Handoffs
Principal Investigator:Vineet Arora MD MAPP

The overall aim of this project is to redesign the end of year handoff process in an internal medicine residency clinic to become more patient-centered by incorporating the patient perspective and their suggestions into this process. To facilitate this redesign, our objectives for this project include: developing an understanding of the ways in which clinic patients perceive the end-of-year handoff process, developing an intervention for internal medicine training that supports a patient-centered end of year handoff, and evaluating the impact of this type of handoff on resident satisfaction, patient satisfaction, and patient outcomes.

The objectives of this project are and continue to be the following: (1) To understand how patients cared for in a resident clinic perceive the end of year handoff process, with a particular focus on barriers and challenges that they face (2) To develop a patient-centered end of year clinic handoff process for internal medicine training (3) To evaluate the impact of this patient-centered end of year clinic handoff process on resident satisfaction, patient satisfaction, and relevant patient outcomes.

EPOCH CLINIC SAFE Pocket Card

American Academy of Pediatrics
Family Feedback Always! (FFA)
Principal Investigator: Aditee Narayan, MD, MPH, FAAP

The goal of Family Feedback ALWAYS! is to develop and assess a pilot program that will enhance communication strategies used by pediatric residents. The program will allow residents to gather meaningful insights and feedback from families they serve in the continuity clinic experience. The program will focus on providing residents with the resources, education and skills to implement the core components of a patient-centered medical home during a 0-2 year old well-child visit. The patient-centered medical home is an approach to providing comprehensive, continuous healthcare that is based on the foundation of a personal relationship between a patient and their family, their physician, and members of a care team. It is facilitated through mutual trust and partnerships that enable bidirectional communication. In turn, critical to this partnership is the physician’s effectiveness in eliciting feedback from patients/families as to the quality of their interactions—this information guides practice improvement as a PCMH.

The following are the specific project aims of FFA!:
• Develop competency-based curriculum materials to enable pediatric residents in the process of eliciting family feedback about their effectiveness in practicing the principals of the PCMH.
• Identify and/or develop measures of effectiveness of resident communication with families.
• Compare the quality and effectiveness of residents eliciting family feedback regarding the quality of their use of PCMH principles before and after utilizing the FFA! curriculum, based on parent/caregiver and self assessments.
• Disseminate curriculum materials and pilot project outcomes to pediatric training programs and other relevant audiences.

Family Feedback Always! (FFA) Project Overview

Crucial Conversations During Critical Life Events

Click to Listen to the October Webinar

Redesigning Discharge

The November 17, 2011 Always Events Learning Network webinar focused on Redesigning Discharge in both inpatient and outpatient settings. Three grantees presented information about their Always Events Initiatives, the lessons they have learned to date, and the tools and resources they have developed or are developing.

Click HERE to view webinar materials and grantee project tools.

Click to Listen to the November

 

 Amplifying Patient and Family Voices: From Listening to Partnering

The December 15, 2011 Always Events Learning Network webinar focused on effective strategies for partnering with patients and families. Four grantees presented information about their Always Events initiatives, the lessons they have learned to date, and the tools and resources they have developed or are developing.

Click HERE to view webinar materials and grantee tools.

Click to Listen to the December Webinar

Patient Safety: Tools and Strategies to Enhance Outcomes 

Click to Listen to the January Webinar

Critical Elements of Communication

The February 16, 2012 Always Events Learning Network webinar focused on ways to enhance communication in the healthcare setting. Five grantees presented information about their Always Events initiatives, the lessons they have learned to date, and the tools and resources they have developed or are developing.

Click HERE to view webinar materials.

Click to Listen to the February Webinar

 Effective Strategies for Educating Both Providers and Patients 

The March 15, 2012 Always Events Learning Network webinar focused on ways to promote effective communication strategies for educating providers and patients. Four grantees presented information about their Always Events initiatives, the lessons they have learned to date, and the tools and resources they have developed or are developing.

Click HERE to view webinar materials.

Click to Listen to the March Webinar

 

 When the Patients are Children: Pediatric Always Events

The April 19, 2012, the Always Events Learning Network webinar focused on effective strategies for enhancing patient and family centered care in the pediatric population. Four grantees presented information about their Always Events initiatives, the lessons they have learned to date, and the tools and resources they have developed or are developing. 

Click HERE to view webinar materilas.

Click to Listen to the April Webinar