10/10/2018 Journey to Home: A Clearly Illustrated Pathway Lisa Mack MSN, BSN, RN III Education Specialist, Transitional Care Center Megan Brammer RTT-NPS, BS Respiratory Therapist II, Transitional Care Center Heather Morath BBA, BSN, RN-BC Project Manager Patient and family Education, Center for Professional Excellence Objectives 1. Describe how a chronic care Journey Board can serve as a visual to help patients and families learn about their care on the pathway to home 2. Understand how the chronic care Journey Board can enhance communication and coordination of care between members of the care team and families Background • Patient and Family Experience • Readmission Reduction • Discharge readiness problem? • Looking for a new approach…. 1
10/10/2018 Collaboration Clinicians Expert Patients & Resources Families Operations Alignment • Work as a team with our families and patients as critical partners • Standardize systems so we can individualize care • Cultivate a collaborative, caring and professional culture • Streamline and simplify, empowering front-line flexibility, decision-making & continuous improvement Purpose • Serve as a visual for use in helping pts/families understand the path they are on and how to care for their child Enhance relationship building , communication , and • collaboration between the family and care team Enhance communication and coordination of care • between members of the care team Provide standardization and continuity of care • 2
10/10/2018 Goals Understanding and Satisfaction of patients and Focusing on engaging , families guiding , and collaborating with families to help them feel Communication and more comfortable & Collaboration across the team confident in caring for their child Readmissions Spread Evidence • Baker, C., Martin, S., et al . A standardized discharge process decreases length of stay for ventilator-dependent children. – Children’s Hospital Colorado; Aurora, CO • Decrease Length of stay • Reduce patient costs • Improve safety 3
10/10/2018 Swim Lanes Children’s Hospital Colorado Map Specific population • Transitional Care Center (TCC) • Pediatric tracheostomy/ventilator unit – 24 bed unit – 10 bed unit at a satellite campus – Neonate to adult population • Average number of families requiring discharge education is 10-15 at any given time 4
10/10/2018 Standardization of care • Ohio Perinatal Quality Collaborative (OPQC) – NICU graduate project • Collaboration between 6 Ohio pediatric hospitals, families and Medicaid • Smart Aim: to successfully transition care to home for NICU infants with complex needs • Focusing on trach/vent/feeding tube population Key Drivers • Strengthened family capacity for care through transition to home preparation • Early and standardized process for transition to home – Need identified from families and staff to clearly identify where patients and caregivers are in process 5
10/10/2018 Standardize education process 1. 4 phases 2. Each block corresponds with specific skills building on previous blocks 3. Stop signs 4. Check-ins to identify barriers and track progress Standardize documentation 1. Clear communication 2. Electronic documentation education tab 3. Track progress towards home in the chart Education documentation 6
10/10/2018 Putting the Journey Board to Use 1. Introduce Journey Board to every family in a pre-trach conference 2. Front cover of education binder 3. Displayed in patients room with markers Collaboration • TCC • NICU • Rehabilitation • Psychiatry Collaboration • Several units wanting to use different versions of the Journey Board for a specific population • Each unit had the end goal of improving their discharge process • Program Manager for patient and family education realized an opportunity for collaboration and standardization amongst different units 7
10/10/2018 Benefits 1. Learn from each other 2. Learning how to spread 3. Keep momentum going General populations 1. Submit application 2. Process outline 3. Ongoing evaluations Care Journey Map (CJM) Process 1. Build your team 2. Gather Information 3. Develop Content 4. Draft Map 5. Get Feedback 6. Integrate into electronic documentation 7. Plan Roll Out 8. Implement Roll Out 9. Ongoing Evaluation 8
10/10/2018 Goals 1. Incorporate communication tool into rounds 2. Standardize trach education throughout the institution 3. Standardize education documentation using “…….Journey to home” template 4. Better system for check-ins Ongoing evaluation • Survey staff 6 months after roll out • Survey families who have received journey board versus families who did not 2 weeks before discharge 9
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