Cross-Continuum Care Transitions:
Dashboard, Discharge Database Streamline Patient Handoffs
As a physician, Dr. Michelle Schneidermann is accustomed to the clinical data driving daily decision-making: blood tests, x-rays, blood pressure readings.
But as part of a multidisciplinary task force charged with improving care transitions within the San Francisco Health Network (SFHN), Dr. Schneidermann faced a "black box" of administrative data buried in more than 60 siloed databases across the health network. Dr. Schneidermann is an associate clinical professor of medicine for the division of hospital medicine at University of California San Francisco/San Francisco General Hospital and medical director of the San Francisco Department of Public Health Medical Respite and Sobering Center.
During Cross-Continuum Care Transitions: A Standardized Approach to Post-Acute Patient Hand-Offs, Dr. Schneidermann described how SFHN's development of a dashboard, a database and uniform practices has helped to streamline care transitions across its care continuum.
Early on, a data analyst pulled together the siloed databases into a cohesive dashboard providing numerous insights on readmission rates, vulnerable populations, and pain points within SFHN—learnings that sparked action plans, pilots and partnerships designed to standardize patient handoffs and post-discharge follow-up.
One key strategy of the task force, which Dr. Schneidermann described as a "multidisciplinary village," was a decision to engage primary care leadership.
"Most of our patients leaving San Francisco General go home from the hospital," said Dr. Schneidermann. "Their post-acute care is in their primary care home. For that reason, we decided that engaging primary care leadership would be a key strategy for our improvement work."
The population served by the network is largely uninsured or underinsured, and at high risk for readmissions, she added.
After piloting post-discharge outreach tactics at three separate primary care clinics, the task force identified a fundamental knowledge gap: the clinics had a hard time identifying which patients had been discharged and when.
Enter a hospital discharge database retrofitted into the electronic medical record (EMR) that populates each night from hospital censuses—a tool that has improved clinic staff workflow.
Not all interventions are technology-driven. The task force has also engaged primary care physician champions, and placed pharmacists in clinics where possible.
Having concluded its second year, much work still remains. Readmission rates have not dropped as low as the task force would like; the impact of behavioral health readmissions on overall rates is now being studied. The task force also hopes to bring the patient's voice to bear.
"In theory, it would be most helpful to have representation from patients with chronic illnesses requiring significant self-management skills, who are also challenged by psycho-social barriers to care," Dr. Schniedermann concluded.
In case you missed this webinar, you still have a chance to watch this highly-rated program.
Register to view the conference today or order your training DVD or CD:
You can "attend" this program right in your office and learn about the development of the care transitions task force and its impact on readmission rates; the role of data dashboards in a care transitions effort; the importance of hospital partnerships with primary and community care to improve care transitions and how to cultivate these partnerships; and the implementation of a standardized approach to outpatient and inpatient care transitions.
It's so convenient! Invite your staff members to watch the conference. We will send you a DVD or CD-ROM of the conference proceedings or a link to our web site with a username and password. You can log in and view the program right from your computer — any time of the day or night, whenever convenient for you and your colleagues — and benefit from the archived recording of the conference, including the Q&A period.
You'll get to listen to the question and answer session to hear details on: special considerations for patients with behavioral healthcare needs during care transitions; the communication strategies to link inpatient and ambulatory staff; how to engage primary care providers in the care transitions process; home visits at SFGH; patient engagement in care transitions; and
the ongoing training, auditing requirements to ensure that a standardized approach is utilized.
To register for the on-demand re-broadcast, download an .MP3 file or order the training DVD or CD-ROM of Cross-Continuum Care Transitions: A Standardized Approach to Post-Acute Patient Hand-Offs, please visit:
I hope you find it useful.
Executive Vice President
The Healthcare Intelligence Network
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