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Models to Reduce Readmissions, an IPF Perspective
IPF Sharing Call Series #1 May 10, 2018
HealthInsight Lake Superior QIN
Models to Reduce Readmissions, an IPF Perspective IPF Sharing Call - - PowerPoint PPT Presentation
Models to Reduce Readmissions, an IPF Perspective IPF Sharing Call - - PowerPoint PPT Presentation
Models to Reduce Readmissions, an IPF Perspective IPF Sharing Call Series #1 May 10, 2018 Lake Superior QIN HealthInsight Objectives Highlight key interventions Inpatient Psychiatric Facilities (IPFs) can use to reduce readmissions
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Objectives
- Highlight key interventions Inpatient Psychiatric Facilities (IPFs)
can use to reduce readmissions
- Stimulate discussion on barriers and successes in the IPF
setting
- Foster cross-collaboration between IPFs across the country
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Timeline RARE Components Project RED Bridges Model
During Stay
Patient / Family Engagement
- Educate patient and family or caregivers.
(Teach Back) Review patient information Confer w/ medical team Educate the patient and caregivers Review how to respond to problems (teach back) Patient Engagement
- Assessment of patient needs
Medication Management
- Medication reconciliation at each transition of
care
- Patient educated re medications. (teach back)
- Address special populations
Identify correct medications Confirms medication plan Follow up on labs Coordinated Care
- Ongoing assessment of patient needs
Transition / Discharge Process
Transition Planning
- Provide a written patient centered transition
plan
- Identify a crisis management plan
Transition Communication
- Educate patient and family on care transition
providers
- Notify primary care and mental health providers
- Send discharge summary
Create after hospital care plan Organize post discharge services and equipment Makes post-discharge follow up appointments Provides patient w/ written discharge plan, teaches them the plan and assesses their understanding of the AHCP. Transmits discharge summary Primary Care Integration Use of Community Resources
- Establish plan of care collaboration
- Provide referrals to community resources
- Educate caregiver on community
resources
Post Discharge Support
Transition Care Support
- Contact the patient within 72 hrs.
Calls to reinforce discharge plan within 48 to 72 hrs. Staff the patient help line Use of Community Resources
- Contact patient and caregivers
- 2 day, 2 wk. and 30 day assessments
Common Core Components
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During the Stay
During the Stay RARE
Patient / Family Engagement
- Educate patient and family or caregivers (teach back)
Medication Management
- Medication reconciliation at each transition of care
- Patient educated re medications (teach back)
- Address special populations
Project RED
- Review patient information
- Confer w/ medical team
- Educate the patient and caregivers
- Review how to respond to problems (teach back)
Bridges Model
Patient Engagement Coordinated Care
- Assessment of patient needs
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Transition / Discharge Process
Transition / Discharge Process
RARE
Transition Planning
- Provide a written patient centered transition plan
- Identify a crisis management plan
Transition Communication
- Educate patient and family re care transition providers
- Notify primary care and mental health providers
- Send discharge summary
Project RED
- Identify correct medications / confirms medication plan
- Follow up on labs
- Create after hospital care plan, provide patient w/ written discharge plan,
teaches them the plan and assesses their understanding of the plan.
- Organize post discharge services and equipment / make post-discharge
follow-up appointments
- Transmits discharge summary
Bridges Model
Primary Care Integration Use of Community Resources
- Establish plan of care collaboration
- Provide referrals to community resources
- Educate caregiver on community resources
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Post Discharge Support
Post Discharge Support RARE
Transition Care Support
- Contact the patient within 72 hrs.
Project RED
- Calls to reinforce discharge plan within 48 to 72 hrs.
- Staff the patient help line
Bridges Model Use of Community Resources
- Contact patient and caregivers
- 2 day, 2 wk. and 30 day assessments
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IPF Sharing Call Series #2 | Risk Stratification and Integrated Care Perspectives in IPF Work
Thursday, May 31 | 1-2 p.m. E.T., 12-1 p.m. C.T., 11 a.m.-12 p.m. M.T., 10-11 a.m. P.T.
HealthInsight will present the READMIT clinical risk index tool that Intermountain Healthcare uses to help identify patients who may be at increased risk for a readmission within 30 days of discharge.
www.LSQIN.org/event/ipfsharingcall2
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This material was prepared by Lake Superior Quality Innovation Network, under contract with the Centers for Medicare and Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The materials do not necessarily reflect CMS policy. 11SOW-MI/MN/WI- G1-18-27 042518
Thank You!
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