Transition of Care Communication
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Transcript Transition of Care Communication
Transition of Care
Communication
from the perspective of the outpatient clinic
Nystrom & Associates, Ltd.
Minnesota Based Mental Health Clinic with eight Minnesota locations and two
Washington state locations.
Over 40,000 unique patient visits per year.
Patient population breakdown:
50% State / Federal Funded (Medicaid / Medicare)
Large commercial payer mix (Blue Cross Blue Shield, Medica, Preferred One, Etc)
Small cash pay population
Collaborative partnerships with many MN, WA, and National Organizations:
Nexus (Mille Lacs Academy, Gerard Academy)
Prairie Care
Health Partners
Medica
Multicare Associates (Fridley, Roseville, and Blaine Medical Centers)
RARE – The Five Key Areas
Patient
/ Family Engagement and Activation
Medication
Management
Comprehensive
Care
Transition Planning
Transition Support
Transition
Communications
Patient / Family Engagement
and Activation
Systemic communication is important from the
start!
The value of the referring entity in getting
Releases of Information.
Family System involvement expectations from
point of referral on.
This
is an active discussion and dialogue!
Medication Management
The
importance of accuracy.
Dossing
expectations and communication.
Existing
Cross
medications
Clinic / Provider illness management.
Additional
resources – Family, Friends, Case
Workers, Group Homes, Etc.
Comprehensive Transition
Planning
Clear plan of services
What follow up, when, where, goals?
Communication of documentation and information
from referent
Set up release of information and communication
expectations with patient at this time.
Care Transition Support
Timelines for care – clear expectations on urgency
(NCQA, Joint Commission, Patient Need)
Care needs, medication management, community
services, psychotherapy, chemical dependency,
etc.
The key to a good referral
Patient
buy in, informed consent, clear communication
and expectations
Transition Communication - The
Culmination of the 5 Key Areas
Back and forth communication expectations.
Needs
of referent, needs of the clinic, needs of the
patient
Release of information on both sides.
Independent
control – what are we able to
take ownership of vs. what do we need to
depend on other for.
Clear
start.
expectations on all areas from the
Collaborative Partnerships and
Care Coordination
Value
of formalizing collaborative
partnerships
Use
of a small handful of providers or one
provider vs. many
Communication
expectations – what to
bring to the table
Time makes all things fuzzy
Over time memory fades.
Importance of writing it down.
Referral guidelines
Memorandum of Understanding
Contracts
Periodic review and check in
If it doesn’t work, FIX IT!
Clear expectations from day 1
Who is involved?
How do they communicate?
When it breaks, who is going to fix it?
Did you write it down?
When good intentions fail
The “set it and forget it” mentality
Assumptions hurt patients care
Failure is an opportunity – Do not overlook it!