Path to Home Overview

What is Path to Home?

Path to Home is an integral access and flow initiativet dd t i d li d tito address acute care service delivery and proactivedischarge planning. It is based on service re-designand integration to create seamless transitions fromadmission to discharge.

Path to Home Goal

Our Path to Home goal is to provide our patients,their families and care team/service providers witha consistent experience via standardizedprocesses, communication strategies, andsupporting technologies.

Path To Home Patient Journeyy

EDT i ED Ph i i A t

Covenant Health Path to Home Model

Allied Health and Clinical Support Services

Decision to Admit (Disposition)

In-patient Acute UnitED Consultation

Disposition to In-patient Bed

Care Team ActivitiesPatient Orientation

Patient BedsideWhiteboards

Patient I f ti

Triage ED Physician Assessment

Disposition to Departure

Allied Health and Clinical Support Services

• Lab: timely specimen collection and results availability for d/c decision making.

• DI: order will require date/priority, test requested, relevant history and clinical reason/expected findings.

• Inpatient units will receive a DI schedule for pt’s with times for next day exams

• Allied Health: Prioritize work activities based on clinical needs, ADOD, resource Care Team Activitiesto UnitBed Management

3 Days Prior to Discharge

Daily Patient Experience

Breakfast/Receive Morning Meds

Assessments/Treatments

Information Package

, ,requirements and availability.

• EVS: Preplanning resource requirements based on ADODs and ETDs.

• Portering: On time arrival and portering back up systems.

Access and Flow

• CTC: centralized management and real-time monitoring.

• Staff utilization: centralized deployment of

Care Management Physician declares and updates ADOD

A.M. & P.M. Rapid Rounds

Patient Bedside Whiteboard Update

Bedside Shift Report

Zone Transition Unit

Daily C

-Home Care

-Supportive Living

-Long Term Care

Community

-Communicate to family of patient discharge-Next day “Green Flag call to MD -Care management notification of transition-Consultant sign off-I-request Pre-Booking prior to 1400h-Preliminary ETD id. for EMS transfer by 1700

ADOD=2 days: Notify Patient / Family for Planned Family Arrival

In patient team updates patient on plan of care

Lunch/Receive Afternoon Meds

Assessments/Treatments

In patient Care Team Updated on

• Staff utilization: centralized deployment of staff based on site needs.

• Transition Services: Care Coordinator / Social Work Dyad model..Day Prior to Discharge

Interprofessional Discharge Checklist

Daily CareCare -Long Term Care

-Mental Health

-Primary CareRestorative Care

/ Sub-acute Review

1700-Notify/confirm next day d/c

In patient Care Team Updated on Care Plan

Dinner/Receive Evening Meds

Day of Discharge

-Early A.M. lab results by program-Discharge order -Confirmed Patient Departure by 1100h -Inititate room turnover-D/C checklist reviewed & given to patient / family upon discharge

Care Management

Care Management

Zone Transition: Acute to

Home Care and LTC

Care

Communication is Critical

A k t t th ti t i i ff tiA key component to the patient experience is effective communication between our team members (Physicians, Nurses, Allied Health, Clinical Support Services, patients/families, and others).

F li i th i ti i th k t tFormalizing the communication is the key strategy we use in Path to Home.

Path to Home Model

Key Framework Componentsy p

Key Framework Components

1. Inpatient Care Team 2. Allied Health & Clinical Support Services

3. Patient Access & Flow pp

ADOD/ETD Lab Care Traffic Control Rapid Rounds Diagnostic Imaging Staff Utilization (ESP) Whiteboards Environmental Services Transition Services

Chart Order & Standardization Portering EMS/IFT Change of Shift Meals & Breaks

Discharge Checklists

Path to Home Roll –Out Schedule

Anticipated Date of Discharge (ADOD)Anticipated Date of Discharge (ADOD)

We introduce an Anticipated Date of Discharge (ADOD) which anchors our discharge pre-planning activities.which anchors our discharge pre planning activities.It is the foundation to all activities leading up to a patient’s discharge.

ADOD – General Principles

Physicians declare ADOD within 24 hours of admission

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Physicians declare ADOD within 24 hours of admission and reviewed daily

Physician documentation on the order sheet in chart should be written as follows:

• ADOD is greater than 5 days • ADOD is less than 5 days• Actual date known

How will ADOD be communicated?

Bedside Whiteboards Rapid RoundsBedside Shift ReportKardex

What are Rapid Rounds?p

Rapid Rounds are: Structured interprofessional rounds that bring the team together to review the patients’ plan of care twice per day.g yRapid Rounds are key in creating the consistent daily communication that is imperative in providing quality and safe patient care.

Rapid Rounds

When?

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Twice daily during the week (A.M & P.M)• A.M. Rapid Rounds: program/Unit dependent start time• P M Rapid Rounds 1330hP.M. Rapid Rounds 1330h

Weekends =Charge Nurse/Physician Touchdown

What Happens During Rapid Rounds?

The A M Rapid Rounds are a brief review (1 minute/patient)

What Happens During Rapid Rounds?

The A.M. Rapid Rounds are a brief review (1 minute/patient) to identify barriers to discharge and to plan care for the patient stay.

The P.M. Rapid Rounds are intended to identify all patients for next day discharge ensure all barriers to discharge arenext day discharge, ensure all barriers to discharge are removed, and finalize the plan.

Rapid Rounds ToolsRapid Rounds Tools

Rapid Rounds Kardex Tool Interprofessional Discharge Ch kli tRapid Rounds Kardex Tool Checklist

MEDICINE INTERPROFESSIONAL DISCHARGE CHECKLIST Patient/ family and Health Care Workers date and initial where appropriate. TO BE COMPLETED BY DISCIPLINE AT BEDSIDE.

**Valuables- Alberta and Covenant Health Services are not responsible for loss of valuables.

INITIALS/ DESIGNATION/ DATE OF COMPLETION

Prescriptions written and given to patient/family □ yes □ not applicable

MEDICATION Medication Counseling □ yes □ not applicable Copy of medication list provided □ yes □ not applicable Name of Pharmacy Faxed to: Blister pack request □ yes □ not applicable

FALL PREVENTION Teaching done □ yes □ not applicable Booklet/Handouts given □ yes □ not applicable

WOUND CARE Copy of updated care plan given to patient & explained □ yes □ not applicable

EQUIPMENT HELP form faxed AND family aware to pick up equipment. Date Faxed: _______________ □ yes □ not applicable

GOALS OF CARE Goals of Care form provided to patient/family □ yes □ not applicable TRANSFUSION TAGS Transfusion tags provided to patient/family □ yes □ not applicable

SHORT STAY DISCHARGE FORM Form provided to patient/ family □ yes □ not applicable

REQUISITION(S) FOR TESTS

Blood-work requisition provided □ yes □ not applicable Home collections set up □ yes □ not applicable Date of bloodwork/ home collections: _________________________________.

HOME COLLECTIONS PHONE NUMBER: 780 453 9440

FOR TESTS BLOOD WORK RESULTS WILL GO TO FAMILY DOCTOR Other requisitions provided for:

RESPIRATORY Home Oxygen Required: □ yes □ not applicable Vendor Name:________________ Phone Number:_____________ Smoking Cessation Education □ yes □ not applicable Other Education:

ANTICOAGULANT MANAGEMENT

Please have INR rechecked on: ________________ _____ □ not applicable AT DISCHARGE, FAMILY DOCTOR IS TO RESUME MANAGING ANTICOAGULANT DOSING.

New Anticoagulant start in hospital; teaching done by pharmacy. □ yes □ not applicable

Home Care Home care referral documents faxed □ yes □ not applicable HOME CARE INTAKE PHONE NUMBER 780 496 1300

PERSONAL BELONGINGS

Valuables Returned: Envelope # ________ □ yes □ not applicable Medications Returned Envelope # _______ □ yes □ not applicable

OTHER DISCHARGE INFORMATION

Patient/ family discharge teaching completed □ yes □ not applicable Transportation arranged with __________________________via: □ Family/ friend by vehicle □ Taxi □ Wheel chair taxi □ Other:________

FOLLOW-UP

APPOINTMENTS BOOKED DATE INFORMATION PRINT NAME/ INITIALS

. Patient / Responsible Party (Print) ____________________ (Signature) ___________________ Date _______________

FACILITY TRANSFER INFORMATION

Continuing care facility notified of patient return date □ yes □ not applicable Transfer orders completed □ yes □ not applicable Discharge time requested per facility:__________________________________ RAAPID form(s) faxed □ yes □ not applicable Other:

Plan of Care Check (CN/BN)Plan of Care Check (CN/BN)

F ll i A M R id R d th B d id N h llFollowing A.M. Rapid Rounds the Bedside Nurse shall refer to the RR kardex for any new updates to the plan of care for each of their assigned pts/and update Charge Nurse on each patient status Prior to P.M. Rapid Rounds the Bedside Nurse will update the Charge Nurse for any patient status changes for nextthe Charge Nurse for any patient status changes for next day discharges

Bedside Whiteboards

Th P ti t B d id Whit b d i t l l dThe Patient Bedside Whiteboard is a tool placed near each patient’s bedside to support communication between the care team, the patient and their family.B d id hit b d h t b t l th tBedside whiteboards have proven to be tools that enhance the patient and family experience. Ensuring consistent updating and sharing of information with our patients and families allows them to becomewith our patients and families allows them to become active participants in their plan of care.

Bedside Whiteboard ExampleBedside Whiteboard Example

Bedside Whiteboards

On admission verbal consent is obtained from the patient pprior to use of the Patient Bedside Whiteboard.The Bedside Nurse will update each of their patient’s whiteboards daily at shift changes and when there arewhiteboards daily at shift changes and when there are any additional changes throughout the day. Allied Health will also update the whiteboards with any changes to the patient’s plan of care and ensure that thechanges to the patient s plan of care, and ensure that the kardex is updated and accurate to reflect the change

Change of Shift – Processes and ToolsChange of Shift Processes and Tools

Shift Introduction Unit Assignment Sheet (UAS) ith M l d B kShift Introduction with Meals and Breaks

GNCH “Shift Introduction” Agenda (Test Concept Units)

Date_____________ Unit____________

I. Key Concepts for the Day: A. Key Messages

B. Commitment to Action

C. Patient Safety

II. Introduction of New Staff to the Team:

III Education:III. Education:

IV. Family Conferences:

V. What’s Happening Today: A. Today’s Discharges/Patient Transfers

B. Potential Next Day Discharges

C. # of OCP beds

D. Observation/Certified Patients

E. Patient Appointments (Refer to Fasting Book)

F. # of Isolations

G. Diagnostic Imaging/Procedure Patient Preparations (Refer to Fasting Book)

H. Sickest Patients on the unit/ Compassionate Care

Bedside Shift Report

The Inpatient Bedside Shift Report/Change of Shift providesf li d f h t f ti l ti t

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a formalized process for how we transfer essential patientinformation safely and hand off responsibilities between ourstaff members.

This allows us to: Provide quality and continuity of patient care during h f hift ti itichange of shift activities

Maintain a safe patient environment Allows patients and families opportunities to participate in p pp p pcare and decision-making.

Change of Shift – BSR Form

Patient Status Updates for Next Shift Report (CN/BN)

The Bedside Nurse will:

S p (C / )

The Bedside Nurse will:complete their bedside shift report forms for each assigned patient

provide the Charge Nurse with any patient updates for next shift report in order to provide the Charge tonext shift report in order to provide the Charge to Charge unit report

Laboratory Services

Lab collection times will be adjusted to provide results of

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next day morning routine tests by defined times.

Thi ill ll lt i ti f it h i i /NPThis will allow results in time for on-unit physician/NP rounding in order to make earlier clinical decisions for the patient plan of care and timely discharges.

Diagnostic Imaging

The ordering prescriber will ensure orders for all DI exams

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g pare complete and include:Procedure requestedDate/priority requiredDate/priority requiredClinically relevant historyClinical Reason/expected findings for the testp g

Diagnostic Imaging ISN Report

EVS Process Map

PorteringPortering

Porters will check in with the Inpatient units on unit arrivalPorters will check in with the Inpatient units on unit arrival when transporting a patient, and notify dispatch on completion of a transport.

Dispatch will notify sending unit if unable to send a porter within a defined period of time.p

Bed Management Model

Principle: The right patient, in the right bed, at the right ti d f b th i ht id

g

time, cared for by the right provider

Bed management consistently anticipates bed capacity and resource needs for the hospital through coordinated responsibilities and tasks.

The Bed Manager, Bed Coordinators, and associated teams (Staffing Office, E i t l S i d P t i ) th ll h it l fEnvironmental Services, and Portering) oversee the overall hospital performance and ensure backup systems are activated at defined thresholds to avoid crisis or over-capacity.

Bed management works collaboratively with all teams and stakeholders to provide safe, appropriate, and timely placement of patients within the hospital

Transition Services

The Care Coordinator & Social Worker Dyad Model is a h d d l t d i i ki l ti hishared and complementary decision-making relationship.

The Care Coordinator and Social Worker develop plansThe Care Coordinator and Social Worker develop plans and make recommendations jointly that impact the patient discharge plan.

Responsibilities and accountabilities overlap significantly, but each partner also has his/her own focus as mutuallybut each partner also has his/her own focus as mutually determined according to role definitions and distribution of workload.

Emergency Medical Services (EMS) and Inter-Facility Transfer Form(IFT)

For standard cases, a request is submitted in IRequest by

a d te ac ty a s e o ( )

For standard cases, a request is submitted in IRequest by 1400 on the day prior to discharge

After receiving discharge transfer requests by1400 EMSAfter receiving discharge transfer requests by1400, EMS Dispatch will schedule each case and provide an estimated time of arrival (ETA) to each respective inpatient unit via IRequest by 1700.y

EMS Transfer BundleEMS Transfer Bundle

Inter-Facility Transfer Form Patient Preparation Job AideInter Facility Transfer Form Patient Preparation Job AidePreparing Patient for Transport

Checklist

Patient’s chart is available and completed by all disciplines.

Your assistance in preparing your patient for transport will support EMS Inter-Facility Transport (IFT) in maintaining timely service to all our service partners.

We respectfully request the following items be completed prior to the arrival of IFT:

Patient’s belongings are packed in one small bag.

p y p

All the patient’s equipment/ attachments are prepared and organized prior to transfer. Please ensure attachments are discontinued as appropriate and any body fluid collections systems are emptied prior to transport (e.g. IV infusions changed to locks, urinary catheter bags emptied, etc.)

Patient’s personal hygiene, nutrition, medication and comfort needs have been met.

Other arrangements have been made for larger items such as wheelchairs, walkers, etc and additional bags. These items present a challenge in securing them safely for transport. If they cannot be safely secured, they will not be transported in the ambulance.

If applicable, a family member or escort is ready to accompany the patient.

How will we know if we are successful?

We will be asking for front line staff feedback throughout theWe will be asking for front line staff feedback throughout the Path to Home journey.A combination of weekly audits and on unit monitoring will occur during the test phase.occur during the test phase.Covenant Health process and outcome measurement will be used.

Organizational Access/FlowgUnit and Site Level Feedback Loops Patient Satisfaction and Workforce Engagement Scores

Questions?

What supports are available to you?