Transcript Smooth Transitions flow chart for Readmissions

DRAFT
SMOOTH COMMUNICATIONS OVERVIEW
Cohesive plan of care between transitions
at arrival and discharge from the hospital
(Stay of less than 24 hours)
1
Community/
Provider
Forum to
Discuss
Effectiveness
Patient Receives Care
in the ED or 23/59
Observation Unit
Hospital Care
Summary
Role of Primary
Care (PC)
Provider or SNF
Hospital/ED Schedule
Patient Appointment
(see triage)
3
Red
24 Hours
Doctor to
Doctor
Phone and
FAX
Orange
3-5 Days (before
Hospital to
PCP Team
Phone and
FAX
Yellow
2 weeks
Hospital to
PCP Team
EHR or FAX
Green
As Needed
Hospital to
PCP Team
EHR or FAX
(if discharge to home)
Follow up by PC
Ensure Appointment
(see triage)
Reinforce
Discharge Plan
Including Medication
Reconciliation
4
4
Patient
Education
Provider
Feedback to
Hospital
What happens prior to hospital care?
What happens during hospitalization?
What happens at discharge?
What happens post discharge?
Communication and Follow-up Based on Patient
Triage/Clinical Need
Appointment
Provider
Exchange
Patient
Needed w/in
Handoff
Mode
3
(electronic/faxed
SNF and/or PC)
Role of Hospital/ED
1.
2.
3.
4.
2
1
4
weekend)
DRAFT
SMOOTH COMMUNICATIONS OVERVIEW
Cohesive plan of care between transitions
at arrival and discharge from the hospital
(Stays more than 24 hours)
1
Patient
Receives Care
in Hospital
Community/
Provider
Forum to
Discuss
Effectiveness
2
Discharge Plan
(electronic/faxed
SNF and/or PC)
4
Patient and
Care Giver
Communication
2
3
Specifics on
Discharge Plan
including
Medications
Hospital Schedule
Patient
Appointment
(see triage)
3
Follow up by PC
Ensure Appointment
(see triage)
1
Reinforce
Discharge Plan
and Medication
Reconciliation
4
Role of Primary
Care (PC) and SNF
2
Education
3
Communication and Follow-up Based on Patient
Triage/Clinical Need
Appointment
Provider
Exchange
Patient
Needed w/in
Handoff
Mode
3
(if discharge to home)
Provider
Feedback to
Hospital
What happens prior to hospital care?
What happens during hospitalization?
What happens at discharge?
What happens post discharge?
Role of Hospital
PC Notified of
Admission
Hospital Follow
Up Call to Patient
1.
2.
3.
4.
4
Patient and Care
Giver Education
4
Red
24 Hours
Doctor to
Doctor
Phone and
FAX
Orange
3-5 Days (before
Hospital to
PCP Team
Phone and
FAX
Yellow
2 weeks
Hospital to
PCP Team
EHR or FAX
Green
As Needed
Hospital to
PCP Team
EHR or FAX
weekend)
Smooth Communications – Transitions in Care
Discussion Questions
1.
What happens when the patient does not have a primary care provider?
• Do we need a separate flow diagram and agreed upon expectations for who does what and
when in this situation which is fairly common?
• How will this change the expectations regarding appointments and the timing of follow-up?
2.
Do we need specific, agreed-upon criteria that will guide the clinical triage of patients at the time of
discharge? Or, is it okay to leave this to the clinical judgment of the discharging provider?
3.
What strategies are likely to be most effective in building accountability and responsiveness among
community physicians for their proactive participation in the patient hand-off’s?
• What are the barriers for community physicians and how can we overcome them most
effectively?
• What do community physicians need to be most effective?
4.
Are hospitals/emergency departments organized and resourced in the most effective way to
effectively facilitate the hand-off’s and provide information?
•
What do hospitals/emergency departments need to be most effective?