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Improving Post Discharge care Dr. Sawad Thotathil Care Coordinates


The problem scenario when the project was initiated 

Winchester hospital was trying to ensure post discharge follow up. This involved a floor RN calling up the practice

Problems faced

 Time away from bedside. Each call could take 10 to 15 minutes  Practice staff could not immediately give appointments as they have to check with the

providers.  Closing the loop through back and forth calls was not practical


Project Scope 

Goal : Improve post discharge patient care by ensuring discharged patient follow up at the PCP office



Objective: Establish simple Facebook-Page-type asynchronous communication between hospitalist team and PCP offices to enable closed loop hand-off communication on discharges and appointments (of Hospitalist patients).


Project metrics 

This project involves ALL Patients having a designated PCP from one of the 6 practices and are cared for by the NEIS hospitalist team at Winchester Hospital

Performance metrics looked at in this project

 Of all patients, % of patients which were followed up by the PCP team soon after

discharge; follow up is defined as a staff member from the practice acknowledges some action has been taken such as “informed MD”, “talked to patient”, “appointment given on date xxx”, “patient seen” etc.  Of all patients, % of patients given an appointment date  Average number of days between discharge date and appointment date


Project course 

Initiated Aug 2012

Practices enter the project over the next few months

Setting up involved –Obtaining agreement of the Practice leader, 1 or 2 sessions of training for practice staff (1 or 2 at each practice either RN ,medical assistant or NP)

Within a couple of months of setting up, this has moved from being a project to becoming the routine system of communication to fulfill the objectives


Why asynchronous group communication is better for Care coordination? 

Care coordination needs coordination between organizations as diverse as senior services to specialist offices

Delays ,bottlenecks and lack of care (at the right time at the right moment) are mostly due to the inability to coordinate the decision making and actions of the different stakeholders.

The operating currency is Information

Depending on One-to-one communication to pass critical information between multiple stakeholders does not succeed because

This channel is only as strong as the weakest link in the chain

 Different stakeholders work in different ‘time zones’ resulting in failure to connect


Benefits of Asynchronous communication 

The problem of the weakest link is overcome by using Broadcasting methods in which if one person is unable or does not pick up and act on a piece of information, another concerned person will pick up on it

If people with different workflows and time conveniences need to connect consistently, they need to be able to leave an information packet to be picked up at the convenience of the other i.e. communicate asynchronously

Behavioral routines of Closing the loop on a request serve to reinforce communication links between persons/teams


Transactional collaboration Broadcasting from team to team


Outcomes on the next 6 slides


Practice - BUR Total Patients Discharged to Practice = 312 120%

Practice - BUR Total Patients with Appt Made = 209 10 9

100%

8 7

80%

Percentage Appt Made Percentage Followed Up

60%

Average # of Days Between D/C & Appt

6 5 4

40%

3 2

20%

1 0% Quarter 3 2012

Quarter 1 2013

Quarter 3 2013

0 Quarter 3 2012

Quarter 1 2013

Quarter 3 2013


Practice = MARK Total Patients Discharged to Practice = 120 120%

Practice = MARK Total Patients with Appt Made = 94 16 14

100%

12 80%

Percentage Appt Made Percentage Followed Up

60%

10

Average # of Days Between D/C & Appt

8 6

40%

4 20%

0% Quarter 4 2012

2

Quarter 2 2013

Quarter 4 2013

0 Quarter 4 2012

Quarter 2 2013

Quarter 4 2013


Practice - TEWK Total Patients Discharged to Practice = 266 120%

Practice - TEWK Total Patients with Appt Made = 189 9 8

100% 7 80%

Percentage Appt Made Percentage Followed Up

6 Average # of Days Between D/C & Appt

5

60% 4 40%

3 2

20% 1 0% Quarter 3 2012

Quarter 1 2013

Quarter 3 2013

0 Quarter 3 2012

Quarter 1 2013

Quarter 3 2013


Practice - WFP Total Patients Discharged to Practice = 287 100%

Practice - WFP Total Patients with Appt Made = 182 14

90%

12

80% 10

70% Percentage Appt Made Percentage Followed Up

60%

Average # of Days Between D/C & Appt

8

50% 6

40% 30%

4

20% 2

10% 0% Quarter 4 2012

Quarter 2 2013

Quarter 4 2013

0 Quarter 4 2012

Quarter 2 2013

Quarter 4 2013


Practice - WMW Total Patients Discharged to Practice = 176

Practice - WMW Total Patients with Appt Made = 85

120%

60

100%

50

80%

Percentage Appt Made Percentage Followed Up

40 Average # of Days Between D/C & Appt

60%

30

40%

20

20%

10

0% Quarter 4 2012

Quarter 2 2013

Quarter 4 2013

0 Quarter 4 2012

Quarter 2 2013

Quarter 4 2013


Practice - WMWo Total Patients Discharged to Practice = 434

Practice - WMWoTotal Patients with Appt Made = 161 18

120%

16 14

100%

12

80%

Percentage Appt Made Percentage Followed Up

60%

Average # of Days Between D/C & Appt

10 8 6

40%

4 20%

0% Quarter 4 2012

2

Quarter 2 2013

Quarter 4 2013

0 Quarter 4 2012

Quarter 2 2013

Quarter 4 2013


What technology was used? 

Salesforce.com platform

This platform has a collaborative tool called Chatter that you saw in the screenshot

Beyond this project, we have gone on to use Chatter for our group’s Nursing home providers (for internal use at this point)

It is possible to use the same platform for virtual care teams focused on individual patients and even get patients communicating


Thank you sawad@neinsp.com 7815308634

Improving post discharge care  
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