F5.Quick Response Care Management - Nial Helgason

Quick Response Care Management

Meeting Patients’ Needs & Engaging Staff

04/15/2023Footer 2

No disclosures

3

Context

The Location Tertiary Hospital Busy Emergency High Acuity Patients

The Client Older Adults Moderate Acuity Risk of Functional

Decline

Objectives / Opportunities

Positive client outcome through intensive case management

Increase clinical collaboration and trust

Purpose

To improve care coordination and communication between Emergency services and Community Integrated Health Services (CIHS).

To follow clients from Emergency to their home and set up supports, and provide short term case management until handover to Home Health.

Steering Committee

Senior LeadershipDecision SupportFundingMeet as requiredBriefing notes

Working Group

Clinical LeadersOperational SupportSystem DesignMeet monthlyProject planning

Care Team

Clinical SupportProblem solvingreviewing caseloadMeet weeklyPDSA cycles

Support Structures

Working Group Nursing: Emergency, In Patient, Community Physicians: Emergency, Hospitalist, G.P. Leadership Quality Improvement

Setting Goals in Care: Assess clients for potential discharge before

admission See client in home next day Prevent Representation

Intervention: Defining Success

7 day a week coverage for nursing and assessment to facilitate daily transition home

Screen of appropriate patients in the Emergency Department who would be followed by the Quick Response team from hospital to home, with a particular focus on those patients presenting in the Emergency Department that are not currently known to Home Health (see appendix 1 for algorithm);

Facilitate improved collaboration and communication between the Emergency Physicians, Hospitalists, General Practitioners and Quick Response Care Managers to build trust in the ability for Home Health program to provide patient care for the target patient population in the community;

Develop relationships with the patient and their family initially in the hospital, followed by a home visit within 24 hours of discharge. The goal of the quick patient follow-up is to increase patient and family confidence in both the Home Health program as well as the patient’s ability to care for themselves at home (see appendix 2 for patient hand out).

Develop individual care plans for each patient, taking into account both the hospital observations and assessment, as well as the home based observations and assessment.

Assign resources for each of the target patients to bridge their care needs between hospital and home with patient follow-up every two week.

Intervention: Roll Description

Intervention: Defining Process

Clinical Team Algorithm describing for

patient movement Mapped the decision

process for staff

Measurement: Evaluation

85% of target patients (those over the age of 75) will receive short term community

supported care within 24 hours of discharge from the Emergency Department

will not be known to Home Health services and programs.

will not be admitted as an inpatient

will not have a subsequent Emergency Department visit for 30 days.

Currently:

91% receive a community visit by the next day

79% of clients are not know to home health

49% are not admitted, while 69% are assessed for Quick Response in the Emergency Department

80% of patients do not represent to the Emergency Department

Measurement: for improvement

Sep

Dec MarAug Nov

0%10%20%30%40%50%60%70%80%90%

100%

QRCM next day visits

Month (2013, 2014, 2015)

Perc

ent

Clients

Seen b

y G

oal

Challenges / Lessons Learned

In developing a plan of care, flexibility is necessary to best meet the needs of the patient

In transition, we need to be approachable for the patient and their family

Touch points for communication are critical to informing staff

Being patient is imperative to building a team

Next PDSAs

Early Identification and flow management of Older Adults in Emergency

Identification of Case Managers in Emergency

Benchmarking Care Plans for frequent Older Adult Emergency Department Users

Identification of revisitsCare Team Identification

Engaging Allied Health