allina hospitals and clinics aftercare proposal

Allina Hospitals and Clinics

Aftercare Proposal

Jamie Otto / Mike Borell / Emily Keenan

Aftercare


The end for doctors and nurses but the beginning for patients and

families.

Start of

Allina Mission Statement


Our MissionWe serve our communities by providing exceptional care, as weprevent illness, restore health and provide comfort to all who entrust us with their care.

Our VisionWe will:

put the patient �rst;

make a di�erence in people’s lives by providing exceptionalcare and service;

create a healing environment where passionate people thriveand excel; and

lead collaborative e�orts that solve our community’s health care challenges.

Our ValuesINTEGRITY We match our actions with our words.

RESPECT We treat everyone with honor, dignity and courtesy.

TRUST We act in the best interests of our patients, physicians,communities and one another.

COMPASSION We create a caring environment for ourpatients and one another.

STEWARDSHIP We use our resources wisely.

Project Purpose Statement


• To explore the information provided to patients before starting at-home recovery.

• In order to empower the patient, connect them to caregivers, and make them more independent and goal-driven in their aftercare.

• So that Allina can facilitate and encourage their patients’ aftercare habits and increase their quality service ratings.

Current Practices


• Sit down before discharge

• Bulky Packets

• Check-in Calls

• Check-in Visits

• Care Guides

Case Studies


JudyGender: FemaleAge: late 50sConnection: Mother to a child who had a heart transplant and has been a patient herselfWhat worked in the past?The personal connection between doctors, extended stay patient, and nurses has been great for her. It became a real community dedicated to the wellbeing of her daughter. She and her daughter used MyChart to show the multiple doctors they were in contact with what medications the other practitioners had her daughter on and keep everything in one place.

What would Judy like to see in aftercare?The family should be included if they will have a large part in the patient’s care, and patients who aren’t frequent hospital visitors should know what questions to ask.

What would Judy like to see inside of the hospital?There should be room for family to go and visitors to stay inside of the rooms. There should also be information about how to take charge of your own care.

How was the communication with the care team? Fantastic, because she took the initiative and learned how to ask the right questions. After spending so much time in medical facilities, she has learned how they function and how to navigate them.

What were some obstacles in aftercare Judy has experienced?Sometimes, working with a hospice nurse is necessary and other times it is not. She has experienced both good and bad ones. Also, there needs to be support for people getting out of surgery since, while she and her daughter did, some people do not have that.

How much access should family or support networks be given?If it is a child, the parents or guardian should have total access. Otherwise, the patient should be able to hand pick what information people are given.

Other Comments:She believes that a patient needs to advocate for themselves and learning how to do that is really how someone successfully takes charge of their own care.

Judy


“It was a stressful situation during release and it was hard to remember what the doctor said later.”

Budd


"In the case of the elderly or those patients that cannot properly take care of themselves, their support networks should be the focus of the aftercare instruction. Either that, or the family and

loved ones should speci�cally have a place to go with their questions."

Dawn


"They are counting on the people to be independent."

Caleb


“If someone is not pushing you to do your physical therapy, it’s impossible to do.”

“There’s things we don’t understand as patients, but doctors need to know.”

Insights


• Information• Emotional Aspects• Disconnect• Patient Driven• Dependence• Family

Current ProposalThe Aftercare CounselorChanges to Online Care

Jamie Otto / Mike Borrell / Emily Keenan


The Aftercare Counselor



•Medical Professional/Counselor/Friend

•Bridge between home and hospital

•From pre-release to end of aftercare



•Answers questions to avoid the

revolving door hospital

•Keeps patients accountable for their

health

•Position can be �lled by medical students,

psychology students, social work students,

and retired doctors and nurses.

What others do


Changes to Online Care


CONGRATULATIONS!

You’ve reached your weekly fitness goal! Celebrate with a

Fruit and Yogurt Parfait.

Because you performed at least 15 minutes of Cardio 5

days this week, you’ve reduced your risk of heart disease by

25%. 0

5

10

15

20

25

30This week

Last Week

0

10

20

30

40

50 Time(mins)

Miles

Miles Ran

Time Vs Miles Ran

YOUR WEEKLY PROGRESS:

Future ProposalThe Aftercare Community


Technological Care


Wireless heart monitors and

pedometers, connected to online

database

Ability to track progress on your

smartphone or personal computer

Retain phone services for those

without Internet access

Structure of the Aftercare Community


CARE GUIDE

SUPPORT NETWORK

SUPPORT NETWORK

SUPPORT NETWORK

SUPPORT NETWORK

SUPPORT NETWORK



CARE GUIDE

SUPPORT NETWORK

SUPPORT NETWORK

SUPPORT NETWORK

SUPPORT NETWORK

SUPPORT NETWORK

CARE GUIDE



CARE GUIDE

SUPPORT NETWORK

SUPPORT NETWORK

SUPPORT NETWORK

SUPPORT NETWORK

SUPPORT NETWORK

Services of anAftercare Community


Home consultations

Group meetings with other locals in

recovery

Advanced technological care

Personalized support connected to

your own existing community, support

network, and home caregivers

Services in the Home


Conversations about recovery

Check-ups with your counselor

Phone calls and online care

In-home cooking lessons with a

licensed dietitian or nutritionist

Connections with Local Area



CCARE GUIDE

SUPPORT NETWORKS

We welcome your comments and feedback


allina hospitals and clinics aftercare proposal

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