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Improving Patient Transitions: Building Social Networks across the Care Continuum Suneela Nayak, MS RN Nan Solomons MS Shelly Shibles, BSN RN

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Page 1: Improving Patient Transitions: Building Social Networks across the Care Continuum Suneela Nayak, MS RN Nan Solomons MS Shelly Shibles, BSN RN

Improving Patient Transitions: Building Social Networks across

the Care Continuum

Suneela Nayak, MS RNNan Solomons MS

Shelly Shibles, BSN RN

Page 2: Improving Patient Transitions: Building Social Networks across the Care Continuum Suneela Nayak, MS RN Nan Solomons MS Shelly Shibles, BSN RN

Learning Points

• Focus on Avoidable Readmissions: Why now?

• How do social network theories help nurses improve safe patient transitions?

Page 3: Improving Patient Transitions: Building Social Networks across the Care Continuum Suneela Nayak, MS RN Nan Solomons MS Shelly Shibles, BSN RN

Why Now?

Avoidable readmissions :

Frequent & costly Issue of quality of care and patient safety Source of dissatisfaction Waste increasingly scarce resources

Page 4: Improving Patient Transitions: Building Social Networks across the Care Continuum Suneela Nayak, MS RN Nan Solomons MS Shelly Shibles, BSN RN

Focus on Reduced Readmissions…

Offers Abundant Opportunities for Nurses to

• Advocate for patient’s agenda for care • Focus on safety, improved outcomes• Develop ability to network across continuum• Fully engage clinical skills, scope of practice

Page 5: Improving Patient Transitions: Building Social Networks across the Care Continuum Suneela Nayak, MS RN Nan Solomons MS Shelly Shibles, BSN RN

MaineHealth Transitions of Care Bundle

1. Risk stratification for readmission

2. Transition Checklist

3. Medication reconciliation

4. Patient/family health education

5. Timely communication among hospital and post-hospital providers

6.Timely follow-up of patients

Page 6: Improving Patient Transitions: Building Social Networks across the Care Continuum Suneela Nayak, MS RN Nan Solomons MS Shelly Shibles, BSN RN

Leading with Innovation

What are

Social Network Theories?

Page 7: Improving Patient Transitions: Building Social Networks across the Care Continuum Suneela Nayak, MS RN Nan Solomons MS Shelly Shibles, BSN RN

Social Network Theories

Social networks consist of:

nodes (people)

ties (relationships)

Page 8: Improving Patient Transitions: Building Social Networks across the Care Continuum Suneela Nayak, MS RN Nan Solomons MS Shelly Shibles, BSN RN

Social Network Theories

S

Isolate

BoundarySpanner

Strong Tie

Weak Tie2-way

1-way

Incoming tie

Outgoing tie

Page 9: Improving Patient Transitions: Building Social Networks across the Care Continuum Suneela Nayak, MS RN Nan Solomons MS Shelly Shibles, BSN RN

Social Network Analysis

Home Health

SNF

LTC

LTC

PCP

Specialty

Social Services

ED

Pharmacy

Discharge Planner

Hospital

Med-Surg

Records

Page 10: Improving Patient Transitions: Building Social Networks across the Care Continuum Suneela Nayak, MS RN Nan Solomons MS Shelly Shibles, BSN RN

Leading with Innovation

How do

Social Network Theories

Help Nurses

Improve Patient Transitions?

Page 11: Improving Patient Transitions: Building Social Networks across the Care Continuum Suneela Nayak, MS RN Nan Solomons MS Shelly Shibles, BSN RN

Evolution of Our Team

WMHCCross-Continuum Team(Expanded)

Stephens Memorial Hospital Transitions Team

Cardinal Health GrantTeam

WMHCCross-Continuum Team

2009 2010 2011 2012

Page 12: Improving Patient Transitions: Building Social Networks across the Care Continuum Suneela Nayak, MS RN Nan Solomons MS Shelly Shibles, BSN RN

2009 Stephens Memorial Hospital: Cardinal Health Grant Team

MaineHealth

SW

OT

QI

CareTransitions

Coach

Physician Practice 1

PTRN

Hospice

RN Mgr

H-H

IT Rx

Acute Care Group

Cardinal Health Team

Page 13: Improving Patient Transitions: Building Social Networks across the Care Continuum Suneela Nayak, MS RN Nan Solomons MS Shelly Shibles, BSN RN

2010: Stephens Memorial Hospital TransitionsTeam

SW

OT

QI

CT Coach

Physician Practice

1

PTRN

Hospice

RN Mgr

H-H

IT Rx

Dir, LTC

Patient Care

Facilitator

LTC RN

Stephens’s Memorial Hospital Transitions Team

Acute Care Network

MaineHealth

Page 14: Improving Patient Transitions: Building Social Networks across the Care Continuum Suneela Nayak, MS RN Nan Solomons MS Shelly Shibles, BSN RN

Improving Transitions: Next Steps

• 2011: CMS quoted the SNF Readmission Rates at 19.8%

• Next Step: Network with regional Long Term and

Skilled Nursing Facilities

Page 15: Improving Patient Transitions: Building Social Networks across the Care Continuum Suneela Nayak, MS RN Nan Solomons MS Shelly Shibles, BSN RN

Western MaineLong Term Care Network

Physician Practice 2

Physician Practice 1

Long Term Care Network

Page 16: Improving Patient Transitions: Building Social Networks across the Care Continuum Suneela Nayak, MS RN Nan Solomons MS Shelly Shibles, BSN RN

2011: Western Maine Cross Continuum Network

SW

OT

QI

Care Transitions

Coach

Physician Practice 1

PTRN

Hospice

RN Mgr

H-H

IT Rx

Director LTC

Patient Care

Facilitator

RN, LTC

Physician Practice

2

MaineHealth

Page 17: Improving Patient Transitions: Building Social Networks across the Care Continuum Suneela Nayak, MS RN Nan Solomons MS Shelly Shibles, BSN RN

2011: Western Maine Cross Continuum Network Ties

Stephens Memorial Hospital Transitions Team

HomeHealth & Hospice

Long Term Care Admin &

Staff

Physician Practice

1

Physician Practice 2

CT Coach

MaineHealth

Page 18: Improving Patient Transitions: Building Social Networks across the Care Continuum Suneela Nayak, MS RN Nan Solomons MS Shelly Shibles, BSN RN

Our Transitions Team Today:

Increased: Comfort Trust Teamwork attributes Engagement Ease of referral Social Worker invited to travel to nursing homes Meetings run over time, no one leaves Daily phone conversations for early problem solving

Page 19: Improving Patient Transitions: Building Social Networks across the Care Continuum Suneela Nayak, MS RN Nan Solomons MS Shelly Shibles, BSN RN

Our Next Steps…

Who else should be at the table?

Page 20: Improving Patient Transitions: Building Social Networks across the Care Continuum Suneela Nayak, MS RN Nan Solomons MS Shelly Shibles, BSN RN

2012: Western Maine Expanded Cross Continuum Network

Acute Care Team

HomeHealth & Hospice

Long Term Care Admin

& Staff

Physician Practice1

Physician Practice2

CareTransitions

Coach

EMS

EMS

Patient

MaineHealth

EMS

Page 21: Improving Patient Transitions: Building Social Networks across the Care Continuum Suneela Nayak, MS RN Nan Solomons MS Shelly Shibles, BSN RN

So…

How has all this

improved outcomes

for our patients?

Page 22: Improving Patient Transitions: Building Social Networks across the Care Continuum Suneela Nayak, MS RN Nan Solomons MS Shelly Shibles, BSN RN

Q1 FY 2008

Q2 FY 2008

Q3 FY 2008

Q4 FY 2008

Q1 FY 2009

Q2 FY 2009

Q3 FY 2009

Q4 FY 2009

Q1 FY 2010

Q2 FY 2010

Q3 FY 2010

Q4 FY 2010

Q1 FY 2011

Q2 FY 2011

Q3 FY 2011

12%

13%

14%

15%

16%

17%

18%

19%

20%

21%

22%

MaineHealth System Performance Q1 FY 2008 - Q3 FY 2011

State : 80th Percentile National: 80th Percentile MH SystemNational 10th Percentile

MaineHealth Readmission Rates: Outcome Measures

Page 23: Improving Patient Transitions: Building Social Networks across the Care Continuum Suneela Nayak, MS RN Nan Solomons MS Shelly Shibles, BSN RN

Questions?

Suneela Nayak, MS RNNan Solomons MS

Shelly Shibles, BSN RN

Improving Patient Transitions:

Building Social Networks across the Care Continuum


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