Continuum of Care: Population Management Presented by: Angelica - PowerPoint PPT Presentation

Continuum of Care: Population Management Presented by: Angelica Starkey RN, MSN and Steve Williams OUI 2015

The Continuum of Care…  What does it mean?  The Continuum of Care as defined by HIMSS: Continuum of Care is a concept involving a system that guides and tracks patients over time through a comprehensive array of health services spanning all levels and intensity of care. The Continuum of Care covers the delivery of healthcare over a period of time, and may refer to care provided from birth to end of life. Healthcare services are provided for all levels and stages of care. ◦ http://www.himss.org/ResourceLibrary/genResourceDetailPDF.aspx?ItemN umber=30272 2

The Continuum of Care…  We (OTTR) discuss this concept in various presentations ◦ Longitudinal Care ◦ Taking Care of Patients Through the Transplant Process Complex  Overlapping   How does OTTR meet the requirements for the continuum of care… 1. System that Guides 2. Tracks patients over time through a comprehensive array of health services spanning all levels and intensity of care 3. Delivery of healthcare over a period of time 4. May refer to care provided from birth to end of life 5. Healthcare services are provided for all levels and stages of care 3

A Syst stem m Tha hat t Guides des  Online referrals automatically insert ◦ Go directly into the work queue  Referrals ◦ Have additional tabs for intake sheets ◦ Referral Plans = Order Set Guide for users to meet center procedures   Evaluations ◦ Include all of the “items” that are considered part of the evaluation Standard items – default checked  Template for Selection Committee documentation   Listings ◦ Action Macros = Order Set Includes all of the standard checklist items  Verify that each item in the list is complete  Forces accountability   Transplant ◦ Action Macros = Order Set  Field Annotations * * 4

Tra rack cks s Pat atients ients Ove ver r Time me  Tracks patients over time through a comprehensive array of health services spanning all levels and intensity of care Transplant Listed Referral Evaluation Post – TX Inpatient • Status 7 Early Outpatient Complications • • • • ICU, PICU, • Status 1 Events Adverse Late Inpatient • • • • Special Care 5

Deli live very ry of Healt lthcar are e Over A Pe Perio iod of Time Listed Post – TX Transplant Referral Evaluation Age 45 5 35 20 40 30 50 10 15 25 6

May y Refer to to Care Provi ovided ded From m Birth h to End of Life fe 7

Healthcare thcare Servi vices ces Are Provided d For All Leve vels And Stage ges of Care  Transplant  Chronic Care ◦ Kidney ◦ Renal Disease ◦ Liver ◦ Liver Failure ◦ Pancreas ◦ Hepatobiliary ◦ Heart ◦ Hepatology ◦ Lung ◦ Heart Failure ◦ Intestine ◦ Cardiology ◦ Islet ◦ Lung Failure ◦ BMT ◦ Intestinal Rehab  Specialty ◦ VAD ◦ Hemoglobinopathy ◦ Vascular Access ◦ Lung Volume Reduction ◦ Diabetes ◦ Liver Research 8

Populat pulatio ion Managem nagement nt  Key OTTR Features for Population Management ◦ Tracked Lists ◦ Dashboards ◦ Repeat Actions ◦ XynManagement 9

Track acked ed Lists ts  Advantages of Tracked Lists ◦ Set of recommended lists by role ◦ Manage your daily activities ◦ Monitor what needs attention 10

Dashboa shboards ds  Advantages of Dashboards ◦ Set of recommended dashboards by role ◦ Visual snapshot of what you care about ◦ Configurable by user 11

Repea peat Actio ions  Advantages of Repeat Actions ◦ Automatically create new action when current action is ended ◦ Site defined frequency options ◦ Default repeat frequency can be overridden when added to patient 12

XynM nManagem agemen ent  Advantages of XynManagement ◦ Risk assessment at both patient and center level ◦ Ensures proper risk factors are identified ◦ Integration with OTTR for patient risk assessment 13

XynM nManagem agemen ent  Center Level Reporting 14

Questio stions ns ? Thank You  15