Transitions of Care Bi-Monthly Meetings

    The “Transitions of Care” zoom meeting’s goal is to improve communication between case management and community providers, especially related to readmissions and start of care following a hospital visit.   The meeting is facilitated by Amy Schmidt, however, this meeting has contributions from multiple case managers from several Oregon and Washington hospitals. It is an open invitation for any case manager to join the discussion. Some may join only once, some participate in only specific topics, a few routinely listen but only participate by chat box,  – any/all levels of participation are welcome. Initially the calls were geographically specific, but we found that many issues overlapped regardless of region. Now, all Oregon & Washington providers meet together on the 1st Tuesday of EVEN months at 11:30am.  This ZOOM call provides thirty minutes of engagement with hospital case management staff, followed by 15 minutes of provider discussion if needed. Any case manager or provider can send agenda topics to  Amy Schmidt.

    Next meeting: April 1, 11:30am

    Zoom Meeting link:
    https://us02web.zoom.us/j/5035055865

    Meeting ID: 503 505 5865
    One tap mobile
    +16694449171,,5035055865# US

    • Link and details from the February 4th zoom, 
      About 115 providers in OR and WA joined the zoom call to discuss how to better facilitate transitions to/from the hospitals. The zoom recording and summary is being shared with hospital case managers. Below I highlighted the biggest barrier for quick discharges from hospital to providers.
      Needs

      • Need for complete and accurate medication lists, including over-the-counter medications.

      • Requirement for patients to be unrestrained for 72 hours before admission to assisted living.

      • Need for 24 hours worth of medications upon discharge from hospital.

      • Requirement for doctor’s orders for bed rails.

      • Need for comprehensive communication between hospitalists and primary care physicians.

      • Requirement for proper documentation of patient’s baseline condition.

      Pain points

      • Lack of communication between hospitals and care facilities regarding patient discharge.

      • Inappropriate discharges from hospitals to assisted living facilities.

      • Incomplete or inaccurate information provided by hospitals when giving referrals.

      • Difficulty in obtaining history and physical information for new residents.

      • Challenges with medication management and orders upon discharge.

      • Issues with updating primary care physicians about medication changes made in hospitals.

      Summary

      • Recording and Introduction of the February 4th Meeting 0:02
        • Speaker 1 confirms the recording of the meeting and mentions the purpose of recording for future reference.
        • Speaker 1 explains the topic of the meeting, focusing on provider needs and challenges in facilitating smooth transitions to and from hospitals.
        • Speaker 1 highlights the impact of staffing issues, inclement weather, and increased occupancy on meeting attendance.
        • Speaker 1 outlines the ground rules for the meeting, emphasizing the importance of avoiding promotional content and sharing best practices to benefit the industry.
      • Challenges in Discharge Processes 4:32
        • Sarah Martin MMC from MMC discusses the challenge of ensuring patients are unrestrained for 72 hours before discharge.
        • Sarah Martin MMC mentions the issue of hospitals discharging patients with only 24 hours’ worth of medications, causing delays in receiving medications from the pharmacy.
        • Speaker 1 clarifies the definition of restraints, including physical and chemical restraints, and their impact on discharge processes.
        • Sarah Martin MMC and other participants discuss the importance of accurate documentation and the challenges posed by bed guards and other restraints.
      • Barriers to Appropriate Discharges 11:36
        • Speaker 1 asks participants about the biggest barriers to appropriate discharges, including paperwork and communication issues.
        • Sarah Martin MMC shares her experience with the 24-hour medication issue and the need for accurate documentation.
        • Speaker 1 mentions the importance of having a doctor’s order for bed rails and the role of Adult Protective Services in ensuring proper documentation.
        • Participants discuss the challenges of medication changes during hospital stays and the need for clear communication between hospitalists and primary care physicians.
      • Communication and Coordination Issues 13:59
        • Candy Cantamessa from KP discusses the communication process between hospitals and primary care physicians, emphasizing the importance of identifying non-member primary care physicians.
        • Irene, a PharmD, highlights the importance of comprehensive medication lists and the role of family members in advocating for patients.
        • Ashley, an admissions director, discusses the challenges of obtaining new narcotic scripts for patients returning from surgery.
        • Speaker 1 emphasizes the need for clear communication and coordination between hospitals and care facilities to ensure smooth transitions.
      • Unique Solutions and Best Practices 25:22
        • Participants share unique solutions and best practices for facilitating smooth transitions, including working closely with discharge planners and being available on weekends.
        • Home health agencies discuss their role in helping with homebound status documentation and obtaining necessary approvals for home care orders.
        • Speaker 1 mentions the use of mobile wound care services and the importance of having access to Epic for better communication.
        • Participants discuss the role of hospice and transportation services in facilitating faster discharges and smoother transitions.
      Link to the “Transitions of Care” zoom recording to view the entire zoom
      Passcode: = r55MULi

    Resources from past meetings:

    View Client/Resident Transfer Form
    Download Client/Resident Transfer Form

     

    Save the dates, Every 2 months on the First Tuesday.