Acute Care Coordination

our patients while utilizing best practices and standardized tools. We’ve observed nurse innovations to better support communications with patients and families during the pandemic. In addition, we’ve seen innovative strategies from our facility leaders who continued leader rounding in support of patients and staff.

Evidence-based teamwork practices, access to care and improved communication strategies have also been embraced by nurses and providers in our ambulatory clinics and settings. Patient experience goals have been developed for our Virtual Care Clinics with supporting resources and evidence- based practices.

In FY2023, we will increase our continuum focus on Home Health and other service lines. We are also continuing to expand our portfolio of resources to include a National “Service Recovery Model” (Humankindness with HEART) and a “Patients as Partners Resource Guide”. We are on a journey to continually improve how our patients, families and others feel about how we care for them, and CommonSpirit nurses are professionals who will lead the way. •

In FY2022, Care Coordination, with involvement from staff throughout all levels of the organization, collaboratively identified our mission, vision and values to unite us in purpose across CommonSpirit. Additionally, Care Coordination leaders created a five-year strategic plan, setting out the tasks, the milestones and the steps needed to transform Care Coordination to meet the needs of our patients and stakeholders. We developed system policies, budget support, and other tools designed to share best practices and enable local leaders to devote more time to their teams and the markets they serve.

Some examples of this system-level partnership and accomplishments include: • Creation of a new department, Care Coordination Regulatory Review Program, to support Care Coordination in completing key functions in accordance with

Dana Farley CMS regulatory

RN, MBA, CCM, guidelines.

System SVP, Additionally, the

Patient Care implementation Coordination-Acute of retrospective reviews of Medicare one-day stays and organization-wide auditing of Care Coordination activities will ensure adherence to CMS regulatory requirements and will reduce risk to our organization.

• Creation of a Utilization Management Hub Model in select markets. This model includes Utilization Review RNs and Concurrent Denial Management RNs working together as one team. The model allows for continuity of work flow through the entire Utilization

Review (UR) process, from admission reviews to challenging payer-issued concurrent denials. Care Coordination also collaborated with Ambulatory Care and Post Acute Care (PAC) to improve the coordination of care across the care continuum (often called 4C efforts).

• Development of a new leader orientation to standardize orientation for new leaders in Care Coordination. Additionally, Inter-rater reliability testing was established for all UR nurses and standardized Care Coordination education was implemented across all sites.

• Identification, in collaboration with Community Health and Population Health, of a core social needs screening domain. Care Coordination assisted in the development of a toolkit for core screening of social needs/social determinants of health.

Other accomplishments included: • Creation of a suicide risk-assessment training and education program for Social Work (SW) staff across CommonSpirit.

• Collaboration with Dignity Health Global Education to create Care Coordination RN and SW residency programs.

• Maintenance of collaborative relationships with post acute care providers (including narrowed networks) to facilitate timely and comprehensive discharge and decrease avoidable delays.

• Continuation of post discharge followups to decrease readmissions and improve the patient experience. •