Continuum of Care: Population Management Presented by: Angelica - - PowerPoint PPT Presentation

Continuum of Care: Population Management

Presented by: Angelica Starkey RN, MSN and Steve Williams

OUI 2015

 What does it mean?  The Continuum of Care as defined by HIMSS: Continuum of

Care is a concept involving a system that guides and tracks patients over time through a comprehensive array of health services spanning all levels and intensity of care. The Continuum of Care covers the delivery of healthcare over a period of time, and may refer to care provided from birth to end of life. Healthcare services are provided for all levels and stages of care.

• http://www.himss.org/ResourceLibrary/genResourceDetailPDF.aspx?ItemN

umber=30272

The Continuum of Care…

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 We (OTTR) discuss this concept in various presentations

• Longitudinal Care
• Taking Care of Patients Through the Transplant Process

 Complex  Overlapping  How does OTTR meet the requirements for the continuum of

care…

• 1. System that Guides
• 2. Tracks patients over time through a comprehensive array of health

services spanning all levels and intensity of care

• 3. Delivery of healthcare over a period of time
• 4. May refer to care provided from birth to end of life
• 5. Healthcare services are provided for all levels and stages of care

The Continuum of Care…

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 Online referrals automatically insert

• Go directly into the work queue

 Referrals

• Have additional tabs for intake sheets
• Referral Plans = Order Set

 Guide for users to meet center procedures  Evaluations

• Include all of the “items” that are considered part of the evaluation

 Standard items – default checked  Template for Selection Committee documentation  Listings

• Action Macros = Order Set

 Includes all of the standard checklist items  Verify that each item in the list is complete  Forces accountability

 Transplant

• Action Macros = Order Set

 Field Annotations *

*

A Syst stem m Tha hat t Guides des

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 Tracks patients over time through a comprehensive array of

health services spanning all levels and intensity of care

Tra rack cks s Pat atients ients Ove ver r Time me

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Referral

• Early
• Late

Evaluation

• Outpatient
• Inpatient

Listed

• Status 7
• Status 1

Transplant

• Inpatient
• ICU, PICU,

Special Care

Post – TX

• Complications
• Events Adverse

Deli live very ry of Healt lthcar are e Over A Pe Perio iod of Time

6 10 15 20 25 30 5

Referral Evaluation Listed Transplant Post – TX Age

35 40 45 50

May y Refer to to Care Provi

• vided

ded From m Birth h to End of Life fe

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 Transplant

• Kidney
• Liver
• Pancreas
• Heart
• Lung
• Intestine
• Islet
• BMT

 Specialty

• VAD
• Hemoglobinopathy
• Vascular Access
• Lung Volume Reduction
• Diabetes
• Liver Research

Healthcare thcare Servi vices ces Are Provided d For All Leve vels And Stage ges of Care

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 Chronic Care

• Renal Disease
• Liver Failure
• Hepatobiliary
• Hepatology
• Heart Failure
• Cardiology
• Lung Failure
• Intestinal Rehab

 Key OTTR Features for Population Management

• Tracked Lists
• Dashboards
• Repeat Actions
• XynManagement

Populat pulatio ion Managem nagement nt

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 Advantages of Tracked Lists

• Set of recommended lists by role
• Manage your daily activities
• Monitor what needs attention

Track acked ed Lists ts

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 Advantages of Dashboards

• Set of recommended dashboards by role
• Visual snapshot of what you care about
• Configurable by user

Dashboa shboards ds

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 Advantages of Repeat Actions

• Automatically create new action when current action is ended
• Site defined frequency options
• Default repeat frequency can be overridden when added to patient

Repea peat Actio ions

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 Advantages of XynManagement

• Risk assessment at both patient and center level
• Ensures proper risk factors are identified
• Integration with OTTR for patient risk assessment

XynM nManagem agemen ent

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 Center Level Reporting

XynM nManagem agemen ent

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? Thank You

Questio stions ns

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