Background Patient and Family Experience Readmission Reduction - - PDF document

10/10/2018 1 Journey to Home: A Clearly Illustrated Pathway

Lisa Mack MSN, BSN, RN III Education Specialist, Transitional Care Center Megan Brammer RTT-NPS, BS Respiratory Therapist II, Transitional Care Center Heather Morath BBA, BSN, RN-BC Project Manager Patient and family Education, Center for Professional Excellence

Objectives

• 1. Describe how a chronic care Journey Board

can serve as a visual to help patients and families learn about their care on the pathway to home

• 2. Understand how the chronic care Journey

Board can enhance communication and coordination of care between members of the care team and families

Background

• Patient and Family Experience
• Readmission Reduction
• Discharge readiness problem?
• Looking for a new approach….

10/10/2018 2

Collaboration

Clinicians Expert Resources Operations Patients & Families

• Cultivate a collaborative, caring and professional culture
• Streamline and simplify, empowering front-line flexibility,

decision-making & continuous improvement

• Work as a team with our families and patients as

critical partners

• Standardize systems so we can individualize care

Alignment

Purpose

• Serve as a visual for use in helping pts/families understand

the path they are on and how to care for their child

• Enhance relationship building, communication, and

collaboration between the family and care team

• Enhance communication and coordination of care

between members of the care team

• Provide standardization and continuity of care

10/10/2018 3

Goals

Understanding and Satisfaction of patients and families Focusing on engaging,

guiding, and collaborating

with families to help them feel more comfortable &

confident in caring for their

child Communication and Collaboration across the team Readmissions

Spread Evidence

• Baker, C., Martin, S., et al. A standardized

discharge process decreases length of stay for ventilator-dependent children.

– Children’s Hospital Colorado; Aurora, CO

• Decrease Length of stay
• Reduce patient costs
• Improve safety

10/10/2018 4

Swim Lanes

Children’s Hospital Colorado Map

Specific population

• Transitional Care Center (TCC)
• Pediatric tracheostomy/ventilator unit

– 24 bed unit – 10 bed unit at a satellite campus – Neonate to adult population

• Average number of families requiring discharge

education is 10-15 at any given time

10/10/2018 5

Standardization of care

• Ohio Perinatal Quality Collaborative (OPQC)

– NICU graduate project

• Collaboration between 6 Ohio pediatric

hospitals, families and Medicaid

• Smart Aim: to successfully transition care to

home for NICU infants with complex needs

• Focusing on trach/vent/feeding tube population

Key Drivers

• Strengthened family capacity for care through transition

to home preparation

• Early and standardized process for transition to home

– Need identified from families and staff to clearly identify where patients and caregivers are in process

10/10/2018 6

Standardize education process

• 1. 4 phases
• 2. Each block corresponds with specific skills

building on previous blocks

• 3. Stop signs
• 4. Check-ins to identify barriers and track

progress

Standardize documentation

• 1. Clear communication
• 2. Electronic documentation education tab
• 3. Track progress towards home in the chart

Education documentation

10/10/2018 7 Putting the Journey Board to Use

• 1. Introduce Journey Board to every family

in a pre-trach conference

• 2. Front cover of education binder
• 3. Displayed in patients room with markers

Collaboration

• TCC
• NICU
• Rehabilitation
• Psychiatry

Collaboration

• Several units wanting to use different

versions of the Journey Board for a specific population

• Each unit had the end goal of improving their

discharge process

• Program Manager for patient and family

education realized an opportunity for collaboration and standardization amongst different units

10/10/2018 8

Benefits

• 1. Learn from each other
• 2. Learning how to spread
• 3. Keep momentum going

General populations

• 1. Submit application
• 2. Process outline
• 3. Ongoing evaluations

Care Journey Map (CJM) Process

• 1. Build your team
• 2. Gather Information
• 3. Develop Content
• 4. Draft Map
• 5. Get Feedback
• 6. Integrate into electronic documentation
• 7. Plan Roll Out
• 8. Implement Roll Out
• 9. Ongoing Evaluation

10/10/2018 9

Goals

• 1. Incorporate communication tool into

rounds

• 2. Standardize trach education throughout

the institution

• 3. Standardize education documentation

using “…….Journey to home” template

• 4. Better system for check-ins

Ongoing evaluation

• Survey staff 6 months after roll out
• Survey families who have received journey

board versus families who did not 2 weeks before discharge