70th AHCA/NCAL Convention and Expo
Effective case management for transitions within and between settings is critical in achieving the Triple Aim of healthcare: improved patient experience, better health of populations, and reduced per capita cost. Systematic, coordinated collaboration of an interprofessional team is required. Focus on a safe, sustainable transition from the start of the episode of care, and advocacy for services to meet each individual’s needs within available resources are central to success.
We will detail 3 transitions best practice standards that our organization implemented:
1 - An established, operational interprofessional team.
2 – Assessing risk for rehospitalization and implementing a tailored care plan based on risk profile.
3 – Conducting a post-admission patient/family conference within 72 hours of admission.
We will define an interprofessional team, and describe the unique role and case management responsibilities of each of the most common team members for successful transitions. Each team member’s unique responsibility in patient activation and engagement will be highlighted.
Video demonstration of an effective Post-admission patient/family conference including discussion of risk profile and care approaches based on risk will be provided, followed by best practice strategies for patient-driven care. The importance of timely, collaborative problem solving and solution-based planning addressing identified risks and barriers will be reviewed.
Evolution of the organizational strategy for standardizing risk identification and management, including lessons learned, will be summarized.
We will illustrate the importance of case management across care settings through organizational examples, including a skilled nursing/home health partnership best practice demonstration project, and a post-discharge follow-up program involving a team of nurses and social workers for targeted centers.
Effective case management that supports successful transitions requires: tight integration of clinical services, patient/family engagement, and continuous coordination among the interprofessional team. This presentation will outline essential elements and illustrate replicable case management best practices that support successful care transitions.