Transcript Care Delivery - Home - Graduate Medical Education

What you need to know about
Care Delivery at Temple
2016 TUHS House Staff Orientation
Lee Buttz, MD, MBA Maryteresa Mintz, BSN
Kevin Banks, RPT
Betty Craig, DNP, CRNP
Care Delivery Team
Review Assessments and Roles of:
1. Physician
2. Nursing
3. Physical Therapy
4. Case Management
5. Social Work
And how they all coordinate as a TEAM in providing
Safe, Timely, Effective, Efficient, Equitable, and
Patient-Centered Care
Physician Role
• Clinical assessment, treatment plan, and
documentation of care
• Medication reconciliation
• Patient and family education
• Transitions of care
• Work rounds (teaching rounds)
• Multi-disciplinary rounds – Patient
Centeredness Care Coordination
Accountable Care Unit (ACU) Model
Each unit is “geographic” and has:
• Unit Based Medical Director (UBMD) who has
oversight of and accountability for unit
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Efficiency of care
Patient throughput
Decreasing variation
Use of clinical care guidelines
Support of patient safety and quality initiatives
• Partnered management with nurse
manager/UBMD and structured multidisciplinary
rounding
Department of Nursing
Telemetry & Pulse Oximetry
• Two classifications for telemetry
– Class I (e.g. a-fib, a-flutter, certain medications)
• If the patient needs to be transported, he/she must be on a
cardiac monitor and accompanied by nurse or doctor (or both)
– Class II (e.g. other diagnoses requiring monitoring)
• The patient can be transported off telemetry without a nurse or
doctor
• All patients requiring telemetry will have IV access
• Pulse Oximetry:
– Verify the physician order for continuous pulse oximetry
– The order must include acceptable range for saturations
Duration of Telemetry
• Patients eligible for removal of telemetry monitoring
will be reviewed at shift report
– Criteria for removal have been established under
the direction of the Cardiology Medical Director
• If a patient meets criteria for removal after 48 hours on
telemetry, then an order must be obtained to
discontinue telemetry
• House staff/resident will be notified
– Attending physician has the option of reordering
telemetry
Falls Prevention
• Any patient designated Low Risk or High Risk is
placed in the Fall Prevention Program
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Morse Scale used to assess fall risk
• The yellow armband (At Fall Risk) is placed on the
same arm as the patient ID band
• A Fall Risk Magnet is placed by the patient name on
the locator board outside the patient’s room and on
the door frame.
• Interventions:
– Use of low rise bed and or bed alarms
– Assure assistance and supervision are provided with elimination, transfers
and ambulation
– Provide patient/family education
– Recommend referral to PM&R for safe ambulation and transfer techniques
What happens if a patient
does fall?
• A Midas Incident/Event report must be entered. It
needs specific information about the fall: Where,
when, how, and whether there is injury?
• Post Fall Assessment to be completed by the team
• Falls are tracked and trended through Midas
• The data is used to help us improve care
Close Observation
Level 11:1 Supervision-Suicide Precautions
Patient who is an immediate threat to
self: Staff must be within arm’s
length of patient-including when in
bathroom
Level 2Field of Vision/Visual Observation
Patient danger to self or others or
at risk for elopement: Staff must be
in same room/area with visual
contact with patient at all times.
2:1 observation permitted
Level 3Enhanced Safety Observation
Patient has delirium/dementia without
violent behavior (may have impulsive
behavior requiring more frequent
observation): Staff must observe
whereabouts, behavior, and patient
condition every 30 minutes
Level 4Fall Precautions
Morse scale to identify fall risk: Staff
must observe whereabouts, behavior,
and patient condition every 60 minutes.
Notify RN if you assess any changes in
patient’s mobility.
When and Why Should Physical
Therapy be Ordered?
• Is the patient at his functional mobility baseline?
• Will medical treatment alone restore the patient to his
baseline level?
• Have there been attempts to mobilize the patient prior
to therapy referral
• Is patient able to participate in therapy?
• Do you plan to transfer to a SNF or Rehab within the
next 48 hours for PT services?
More about PT
PT is contraindicated if:
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Spine not cleared from trauma/METS
X-rays/MRI pending
No clear Weight Bearing status
Patient with BEDREST activity orders
HgB <7
INR > 5
PT is not necessary if:
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Safely discharging home
Want home PT for endurance or safety check
Want outpatient PT for chronic issues
Patient is baseline functionally
Want a walking pulse ox
Other PM&R Services
Occupational Therapy:
Upper extremity dysfunction
Hand/arm/shoulder splinting
Splint, boots, shoes
Activities of Daily Living
dysfunction
Acute Rehab assessment
Speech Pathology Services:
Diagnostic and therapeutic
services forDysphagia
Speech-Language dysfunction
Cognitive Impairments
Voice Disorders
Mobility Aides:
Trained aides to enhance
patient mobility. Prevent
patient debility that can cause
secondary complications
Physical Medicine and
Rehabilitation:
Consider early consult for
musculoskeletal related issues
or need for inpatient rehab.
CLINICAL RESOURCE
MANAGEMENT DEPARTMENT
Primary functions• Coordinate a safe and timely discharge plan
• Monitor and decrease length of stay
• Secure reimbursement for care
• Collaboration with the team
• Daily Accountable Care Unit interdisciplinary
rounds
What is needed from you?
• H & P MUST be in the medical record for all
members of the team to begin their work
• Document patient’s contact numbers in the
H & P if you interview care giver/community
representative
• Clearly documented plan of care
• Participation in unit based rounds
• Forms and prescriptions completed timely
• Communicate, Communicate, Communicate
How we can assist you?
• Case Managers and Social Workers can
assist you with developing the plan for a safe
transition to after care
• Consult with team to determine appropriate
level of care for transition
• Available as a resource to you and team
When to consult Social
Worker
• Patient incapable of
decision-making
• No next of kin
information
• Social Work to assess
provision of resources in
the community to local
health district and public
welfare office
• Suspicion of Domestic
Violence, Child or Elder
Abuse
• Patient admitted with a
psychiatric involuntary
(302) or voluntary (201)
need for continued
psychiatric treatment
when medically stable
• Patient has active drug
or alcohol issues
• Assistance in placement
of homeless patients
Case Management- Discharge
Planning Considerations
Home Care
• Visiting Nurse
• PT
• IV Therapy
• OT
• Speech
• Home care aide
• Home Hospice
Skilled Facility
Acute Rehabiltation
• Needs qualifying
• PT needs
diagnosis
• Wound Care
• Insurance
• Wound Vac
authorization
• IV antibiotic therapy
• PM&R team will
• Inpatient Hospice
provide physical,
• Needs insurance authorization occupational, and
speech therapies
Long Term Acute Care Hospital (LTACH)
• Daily Physician Assessment
• Ventilator weaning
• Complex wound care
Discharge Coordination
• Special Circumstances: Chronic Dialysis
– Skilled facility placement must be coordinated with the
dialysis Social Worker
– Patient agrees to hemodialysis site and Skilled Nursing
Facility
• Insurance authorization must be obtained
• Patient medically cleared for transfer is documented
• Final arrangements made, time of transport
communicated
• Transfer orders complete before time of discharge
Summary
• Temple patients are complex!
• Care delivery requires a
multidisciplinary approach and great
teamwork
• Take advantage of your Temple Team:
Everyone is here to help you provide
safe, timely, efficient, effective,
equitable, and patient-centered care
• Welcome to your TUHS experience!