Patient Flow Janet Gillen, LCSW Director of Social Services - PowerPoint PPT Presentation

Patient Flow Janet Gillen, LCSW Director of Social Services Patient Flow Coordinators: Debbie Tam, RN Ghodsi Davary, RN May 27, 2014

Recent Years of Pivotal Change for Long- Term Care Community ● Community providers experiencing the loss of 300+ Laguna Honda beds and closure of other community SNF beds in an aging population - ongoing pressure from hospitals and community for LHH beds ● DPH Strategic Goal of Integration and appropriate level of care resulting in improved Patient Flow ● Successful closure of the Chambers class action lawsuit and its focus on community re-integration and wrap-around services ● Implementation of ACA-San Francisco Health Network and its Managed Care system

Operational Changes Staff and resident/family education and participation in transitioning the residents to ● their appropriate level of care Education to referring Hospital Discharge Planners on Lower Level of Care options ● Using Data Measures to quantitatively measure goal progress ● Increasing bed utilization and turnover ● Decreasing wait time for admission ● Creation of 15 bed Discharge Household on N3 ● LHH accepts weekend admissions ● LHH Social Services shares access to the Placement Referral Tracking System ● LHH Patient Flow Coordinator integrated into SFGH discharge meetings and ● monitors census, admissions and discharges daily

Staff Education and Participation ● Ninety-five percent completion of Healthstream Module on Appropriate Level of Care ● Revision of language in the Conditions of Admission and Laguna Honda Rules and Responsibilities ● All Resident Care Teams attended a DCIP (Diversion Community Integration Program) meeting ● Social Services Department held 4 Discharge Fairs a year for residents, families and staff on discharge resources

Data Measures Monthly Census reports developed and available for managers for ● review Ongoing review of resident appropriate level of care data measures ● High level Dashboard utilized by San Francisco Health Network ● leadership to monitor patient flow LHH Classification of Discharge Barriers is in process now that will ● be populated by Social Services and Quality Management Monitoring outcome of discharges ●

New Admissions & Community Discharges: Q1 2011 – Q1 2014

Internal Changes: Micro level ● Weekly Discharge Huddles on each neighborhood ● QM and Rehab assigned a representative to every discharge huddle ● Discharge Resource icon on the Intranet ● Admission and Screening Committee to meet twice a week and as needed, to increase internal efficiency ● Monthly Behavioral Placement Rounds ● Clinical Leadership Rounds ● Involved Activity Therapy and Pharmacy Departments

Internal Changes: Macro level Regular meetings with Placement Team and Housing Partners to review ● residents on wait-list Partnered with IHSS to do “Early Track” training ● Partnering with CBHS for SATS, Psych staff, Nursing Managers and Social ● Workers Increased family and conservator attendance at Resident Care Conferences ● Medical Respite tour for Exec Team ● Growing the respite program ● Increasing our use of 2-3 day trials at home ● Successfully transitioned 11 Behavioral Health Center clients in 2012 and 12 ● clients in 2013 to LHH. Repatriated 6 locked facility residents from out-of- county to LHH.

Results Thus Far ● Our average wait time for admissions from 12/1/12 to 12/31/13 was 3.91 days down ● Discharges have increased for 2013 (252) from 2012 (185) and numbers look good for 2014 ● Increased SNF beds from 765 to 769 capacity ● Number of patients served from 2012 to 2013 was 1,191.

Future Challenges ● Remaining viable and thriving in managed care environment ● San Francisco Health Network: Can LHH residents discharge in less than 60 days?