What you need to know about Care Delivery at Temple

2014 TUHS House Staff Orientation

Care Delivery Team

Review Assessments and Roles of:1. Physician 2. Nursing 3. Physical Therapy 4. Case Management 5. Social Work And how they all coordinate as a TEAM in providing Safe, Effective, Efficient, Timely, and Patient-Centered Care

Physician Role

• Clinical assessment, treatment plan, and documentation of care

• Medication reconciliation• Patient and family education• Transitions of care• Work rounds (teaching rounds)• Multi-disciplinary rounds -Care Coordination

Accountable Care Unit (ACU) Model

Each unit is “geographic” and has:• Unit Based Medical Director (UBMD) who has oversight

for and accountability for unit• Efficiency of care• Patient throughput• Decreasing variation• Use of clinical care guidelines• Support of patient safety and quality initiatives

• Partnered management with nurse manager/UBMD leaders and structured multidisciplinary rounding- in transition

Interdisciplinary Plan of Care

• Goal: – Patient focused– Disciplines add to the IPOC as they become

involved in the patient’s care

• Where : The IPOC is located in the Care Plan tab of the Medical Record

Department of Nursing

Telemetry & Pulse Oximetry• Two classifications for telemetry

– Class I (e.g. a-fib, a-flutter, certain medications)• If the patient needs to be transported, he/she must be on a

cardiac monitor and accompanied by nurse or doctor (or both)

– Class II (e.g. other diagnoses requiring monitoring)• The patient can be transported off telemetry without a nurse or

doctor• All patients requiring telemetry will have IV access

• Pulse Oximetry:– Verify the physician order for continuous pulse oximetry – The order must include acceptable range for saturations

Duration of Telemetry

• Patients eligible for removal of telemetry monitoring will be reviewed at shift report– Criteria for removal have been established under

the direction of the Cardiology Medical Director• If a patient meets criteria for removal after 48 hours on

telemetry, then an order must be obtained to discontinue telemetry

• House staff/resident will be notified– Attending physician has the option of reordering

telemetry

Falls Prevention • Any patient designated Low Risk or High Risk is

placed in the Fall Prevention Program- Morse Scale used to assess fall risk

• The yellow armband (At Fall Risk) is placed on the same arm as the patient ID band

• A Fall Risk Magnet is placed by the patient name on the locator board outside the patient’s room and on the door frame.

• Interventions:– Use of low rise bed and or bed alarms– Assure assistance and supervision are provided with elimination, transfers

and ambulation– Provide patient/family education– Recommend referral to PM&R for safe ambulation and transfer techniques

What happens if a patient does fall?

• A Midas Incident/Event report must be entered. It needs specific information about the fall: Where, when, how, and whether there is injury?

• Post Fall Assessment to be completed by the team • Falls are tracked and trended through the Midas

report• The data is used to help us improve care

Level 1-1:1 Supervision-Suicide PrecautionsPatient who is an immediate threat to self: Staff must be within arm’s length of patient-including when in bathroom

Level 2-Field of Vision/Visual ObservationPatient danger to self or others orat risk for elopement: Staff must be in same room/area with visual contact with patient at all times. 2:1 observation permitted

Level 3-Enhanced Safety ObservationPatient has delirium/dementia without violent behavior (may have impulsive behavior requiring more frequent observation): Staff must observe whereabouts, behavior, and patient condition every 30 minutes

Level 4-Fall PrecautionsMorse scale to identify fall risk: Staff must observe whereabouts, behavior, and patient condition every 60 minutes.Notify RN if you assess any changes in patient’s mobility.

Close Observation

TUH Clinical Escalation.url

When and Why Should Physical Therapy be Ordered?

• Is the patient at his functional mobility baseline?

• Will medical treatment alone restore the patient to his baseline level?

• Have there been attempts to mobilize the patient prior to therapy referral

• Is patient able to participate in therapy?

• Do you plan to transfer to a SNF or Rehab within the next 48 hours for PT services?

More about PTPT is contraindicated if:

• Spine not cleared from trauma/METS• X-rays/MRI pending• No clear Weight Bearing status• Patient with BEDREST activity orders• HgB <7• INR > 5

PT is not necessary if:• Safely discharging home• Want home PT for endurance or safety check• Want outpatient PT for chronic issues• Patient is baseline functionally• Want a walking pulse ox

Other PM&R Services Occupational Therapy:Upper extremity dysfunctionHand/arm/shoulder splintingSplint, boots, shoesActivities of Daily Living dysfunctionAcute Rehab assessment

Speech Pathology Services:Diagnostic and therapeutic services for-DysphagiaSpeech-Language dysfunctionCognitive ImpairmentsVoice Disorders

Mobility Aides:Trained aides to enhance patient mobility. Prevent patient debility that can cause secondary complications

Physical Medicine and Rehabilitation:Consider early consult for musculoskeletal related issues or need for inpatient rehab.

CLINICAL RESOURCE MANAGEMENT DEPARTMENT

Primary functions-• Coordinate a safe and timely discharge plan• Monitor and decrease length of stay • Secure reimbursement for care• Collaboration with the team• Daily Accountable Care Unit interdisciplinary

rounds

What is needed from you?• H & P MUST be in the medical record for all

members of the team to begin their work • Document patient’s contact numbers in the

H & P if you interview care giver/community representative

• Clearly documented plan of care• Participation in unit based rounds• Forms and prescriptions completed timely• Communicate, Communicate, Communicate

How we can assist you?

• Case Managers and Social Workers can assist you with developing the plan for a safe transition to after care

• Consult with team to determine appropriate level of care for transition

• Available as a resource to you and team

When to consult Social Worker• Patient incapable of decision-making• No next of kin information• Social Work to assess provision of resources in the

community to local health district and public welfare office

• Suspicion of Domestic Violence, Child or Elder Abuse

• Patient admitted with a psychiatric involuntary (302) or voluntary (201) need for continued psychiatric treatment when medically stable

• Patient has active drug or alcohol issues• Assistance in placement of homeless patients

Case Management- Discharge Planning Considerations

Home Care• Visiting Nurse• PT• IV Therapy• OT• Speech• Home care aide• Home Hospice

Long Term Acute Care Hospital (LTACH)• Daily Physician Assessment• Ventilator weaning• Complex wound care

Skilled Facility• PT needs• Wound Care• Wound Vac• IV antibiotic therapy• Inpatient Hospice• Needs insurance authorization

Acute Rehabiltation• Needs qualifying

diagnosis• Insurance

authorization• PM&R team will

provide physical, occupational, and speech therapies

Discharge Coordination

• Special Circumstances: Chronic Dialysis– Skilled facility placement must be coordinated with the

dialysis Social Worker– Patient agrees to hemodialysis site and Skilled Nursing

Facility

• Insurance authorization must be obtained• Patient medically cleared for transfer is documented• Final arrangements made, time of transport

communicated• Transfer orders complete before time of discharge

Home Discharge Plan

• Patient has made progress in physical therapy• Therapist recommends continued PT at Home• Team modifies medication regime to insure

adherence• Case Manager informed of plan and suggests

Visiting Nurse, PT, and Home Health Aide• Home infusion arrangements • Agency selected; must coordinate with hemodialysis• Informs team, discharge instructions completed

Temple Access Center

Need an appointment for a patient being discharged?• Place an order in MIS (Computerized Physician

Order Entry system)- it goes to our Access Center• 2 hour turn around time for referral in-system, 24

hour turn around for external referrals• Access Center will make the appointment and

enter it directly into MIS in the discharge instructions

Summary

• Temple patients are complex!• Care delivery requires a multidisciplinary approach and great teamwork

• Take advantage of your Temple Team- everyone is here to help you provide safe, efficient, effective, timely, equitable and patient-centered care

• Welcome to your TUHS experience!