Transition of Care – Update

By Wanda Kimbrough and Kathy Bleidorn

For the past several months, a team of staff from integrated care management; nursing; emergency departments; and Fidelity, have been working on strategies to further improve ways to move patients along the continuum of care and to reduce readmissions. As a result, the following changes have been made and will go into effect on December 1, 2014:

LACE tool scoring revision—has been revised to take into account patient conditions such as behavioral health issues, certain social aspects, and the complexity of renal patients. The high alert score remains >11; however, you may note an increase in the number of patients at this level or higher, with the implementation of the revision.

Rooming-in—designates a program that allows the patients’ primary caregiver to stay in the hospital to provide the necessary required care, and affords an opportunity for home primary caregivers to obtain training and instruction under the supervision of nursing, while in the hospital setting. The decision to offer rooming-in is up to the care team, and should be offered in advance of the day of discharge, if possible. You will be notified by the nurse that this option has been selected To be considered, patients and their caregivers should be actively involved in their discharge planning, may have extra needs, and have elected not to go to an extended care or skilled nursing facility.

“Green dot” in the ED—patients who arrive in the ED, and who are a potential readmission, will have a “green dot” alert in EPIC to notify ICM and ED nursing staff of a potential t readmission. This will trigger a more intensive look into the patient’s history, including the previous admission, to identify possible reasons for the return to the ED. If reasons are identified, actions will be taken, based on the patient’s status, to work with the provider to avoid repeating a situation that caused the patient to be readmitted or to return to the ED.

If you have specific questions or concerns, please contact Wanda Kimbrough, or a member of the ICM staff.

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Source: Wanda Kimbrough and Kathy Bleidorn

Content Updated: March 25, 2015

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