transition of care communication from the perspective of the outpatient clinic
TRANSCRIPT
![Page 1: Transition of Care Communication from the perspective of the outpatient clinic](https://reader030.vdocuments.mx/reader030/viewer/2022032722/56649f425503460f94c6120a/html5/thumbnails/1.jpg)
Transition of Care Communication
from the perspective of the outpatient clinic
![Page 2: Transition of Care Communication from the perspective of the outpatient clinic](https://reader030.vdocuments.mx/reader030/viewer/2022032722/56649f425503460f94c6120a/html5/thumbnails/2.jpg)
Nystrom & Associates, Ltd. Minnesota Based Mental Health Clinic with eight Minnesota locations
and two Washington state locations. Over 40,000 unique patient visits per year. Patient population breakdown:
50% State / Federal Funded (Medicaid / Medicare)
Large commercial payer mix (Blue Cross Blue Shield, Medica, Preferred One, Etc)
Small cash pay population
Collaborative partnerships with many MN, WA, and National Organizations: Nexus (Mille Lacs Academy, Gerard Academy)
Prairie Care
Health Partners
Medica
Multicare Associates (Fridley, Roseville, and Blaine Medical Centers)
![Page 3: Transition of Care Communication from the perspective of the outpatient clinic](https://reader030.vdocuments.mx/reader030/viewer/2022032722/56649f425503460f94c6120a/html5/thumbnails/3.jpg)
![Page 4: Transition of Care Communication from the perspective of the outpatient clinic](https://reader030.vdocuments.mx/reader030/viewer/2022032722/56649f425503460f94c6120a/html5/thumbnails/4.jpg)
RARE – The Five Key Areas Patient / Family Engagement and
ActivationMedication ManagementComprehensive Transition Planning Care Transition SupportTransition Communications
![Page 5: Transition of Care Communication from the perspective of the outpatient clinic](https://reader030.vdocuments.mx/reader030/viewer/2022032722/56649f425503460f94c6120a/html5/thumbnails/5.jpg)
Patient / Family Engagement and Activation Systemic communication is important from
the start! The value of the referring entity in getting
Releases of Information. Family System involvement expectations
from point of referral on. This is an active discussion and dialogue!
![Page 6: Transition of Care Communication from the perspective of the outpatient clinic](https://reader030.vdocuments.mx/reader030/viewer/2022032722/56649f425503460f94c6120a/html5/thumbnails/6.jpg)
Medication ManagementThe importance of accuracy.Dossing expectations and
communication.Existing medicationsCross Clinic / Provider illness management.
Additional resources – Family, Friends, Case Workers, Group Homes, Etc.
![Page 7: Transition of Care Communication from the perspective of the outpatient clinic](https://reader030.vdocuments.mx/reader030/viewer/2022032722/56649f425503460f94c6120a/html5/thumbnails/7.jpg)
Comprehensive Transition Planning Clear plan of services What follow up, when, where, goals? Communication of documentation and
information from referent Set up release of information and
communication expectations with patient at this time.
![Page 8: Transition of Care Communication from the perspective of the outpatient clinic](https://reader030.vdocuments.mx/reader030/viewer/2022032722/56649f425503460f94c6120a/html5/thumbnails/8.jpg)
Care Transition Support
Timelines for care – clear expectations on urgency (NCQA, Joint Commission, Patient Need)
Care needs, medication management, community services, psychotherapy, chemical dependency, etc.
The key to a good referral Patient buy in, informed consent, clear
communication and expectations
![Page 9: Transition of Care Communication from the perspective of the outpatient clinic](https://reader030.vdocuments.mx/reader030/viewer/2022032722/56649f425503460f94c6120a/html5/thumbnails/9.jpg)
Transition Communication - The Culmination of the 5 Key Areas Back and forth communication expectations.
Needs of referent, needs of the clinic, needs of the patient
Release of information on both sides.
![Page 10: Transition of Care Communication from the perspective of the outpatient clinic](https://reader030.vdocuments.mx/reader030/viewer/2022032722/56649f425503460f94c6120a/html5/thumbnails/10.jpg)
Independent control – what are we able to take ownership of vs. what do we need to depend on other for.
Clear expectations on all areas from the start.
![Page 11: Transition of Care Communication from the perspective of the outpatient clinic](https://reader030.vdocuments.mx/reader030/viewer/2022032722/56649f425503460f94c6120a/html5/thumbnails/11.jpg)
Collaborative Partnerships and Care CoordinationValue of formalizing collaborative
partnershipsUse of a small handful of providers or
one provider vs. manyCommunication expectations – what to
bring to the table
![Page 12: Transition of Care Communication from the perspective of the outpatient clinic](https://reader030.vdocuments.mx/reader030/viewer/2022032722/56649f425503460f94c6120a/html5/thumbnails/12.jpg)
Time makes allall things fuzzy
Over time memory fades.
Importance of writing it down. Referral guidelines
Memorandum of Understanding
Contracts
Periodic review and check in
If it doesn’t work, FIX IT!
![Page 13: Transition of Care Communication from the perspective of the outpatient clinic](https://reader030.vdocuments.mx/reader030/viewer/2022032722/56649f425503460f94c6120a/html5/thumbnails/13.jpg)
Clear expectations from day 1 Who is involved? How do they communicate? When it breaks, who is going to fix
it? Did you write it down?
![Page 14: Transition of Care Communication from the perspective of the outpatient clinic](https://reader030.vdocuments.mx/reader030/viewer/2022032722/56649f425503460f94c6120a/html5/thumbnails/14.jpg)
When good intentions fail
The “set it and forget it” mentality Assumptions hurt patients care Failure is an opportunity – Do not overlook
it!
![Page 15: Transition of Care Communication from the perspective of the outpatient clinic](https://reader030.vdocuments.mx/reader030/viewer/2022032722/56649f425503460f94c6120a/html5/thumbnails/15.jpg)