Theme 5. Coordinating care to create better transitions
Presentation Details
- Date: 10/18/2016
- Concurrent Session D
- Time: 9:30am – 10:15am
- Room: Pier 5
- Style: Presentation (information provided to audience, with opportunity for audience to ask question)
- Focus: Practical (e.g. Presentation on how to implement programs and/or practices in the team environment)
- Target Audience: Leadership (ED, clinical lead, board chair, board member, etc.), Clinical providers, Administrative staff, Representatives of stakeholder/partner organizations
Learning Objectives
- Learn how to improve patient safety as well as improve their health care journey while transitioning from hospital to home and home to hospital
- Examine ways to prevent hospital re-admissions for both chronic and acutely ill patients
- Examine the care needs that can be addressed within a patients’ home post-hospital discharge
Summary/Abstract
By October of 2016 we hope to have used our tracking codes and nearly full year of running the Transitions program to determine the following outcomes:
- The number of patients followed up by Transitions who still required readmission to hospital within 30 days of discharge
- Which medical diagnoses required the most follow-up and referrals, and to which disciplines
- How many home visits were done
- How many Primary Care Provider (PCP) visits were booked through Transitions and how many of these were within 7 days of hospital discharge ; if > than 7 days then why?
- The number of times a patient or family member called in to their Transitions program point person with questions or concerns
- How many hospital visits were completed through the Transitions program
- Qualitative data about the patient/family experience using surveys
- We hope to see that readmission rates within 30 days decrease over time. In keeping with our Schedule A and QIP targets, we hope to see > 80 home visits completed and 100 PCP appointments booked with >50% of PCP visits done within 7 days of hospital discharge. Finally, we hope to see >400 pts at the bedside to initiate the transition from hospital to home.
Presenters
- Danielle Duns, Lead RN, Transitions Program, Markham FHT
- Lisa Ruddy, RN, Clinical Program Manager, Markham FHT
- Rebecca Robinson, Administrative Assistant, Markham FHT