On the road toward transitions of care

Wednesday, May 30, 2018

In the past few months, Purdue Healthcare Advisors, the Indiana Hospital Association and QSource spent time with clinicians and administrators in several locations around the state in an effort to drive improvements in transitions of care between various clinical settings. More than 300 people attended from hospitals, ambulatory settings (primary care/specialist/FQHC clinicians), nursing homes, and home health agencies.

Touchdowns in Transitions of Care – the four-hour Learning and Action Network (LAN) events – focused on the process of change management for improving care transitions across the healthcare continuum. Attendees heard from Harrison County Hospital presenters, who worked in collaboration with PHA lean experts through the GLPTN+LEAN initiative to implement a Transitional Care Management (TCM) program.

The audience heard about the four-day Rapid Improvement Event (RIE) that brought together a cross-functional team from the hospital and ambulatory clinics to redesign a workflow that would support TCM services. Through the RIE, Harrison County Hospital stood up a new TCM workflow and daily huddle to discuss and monitor the status of their key metrics which included: 1) hospital discharge by 5pm, 2) no show/cancellation rate of follow-up appointments, and 3) TCM codes filed without error.  The hospital not only achieved all of their metrics, but sustained them for more than nine months while expanding the reach to non-employed, community providers. Additionally, they created an internal tool that eases communication between the in-patient staff, ambulatory staff, and the patients that has resulted in improved patient satisfaction scores.

Attendees left with the goal of changing current practices or, at minimum, starting to track no shows and cancellations.

“Transitions of care are instrumental in the work performed by PHA, Qsource and the IHA, so orchestrating a combined session provided the cross-cutting engagement neded to connect community partners, who will hone the work at the local level,” said Allison Bryan Jungels, PHA’s Senior Advisor-GLPTN Network QI Lead, and GLPTN Indiana Program Manager. “This approach seemed to serve our clients well as many expressed their appreciation for having multiple healthcare sectors participate in the conversation.”

Feedback from attendees:

  • Great stories & excellent explanations of TCM & why important
  • I will be problem solving much differently now—principles for testing very valuable
  • Clearer understanding of direct impact on readmissions & PCP visits


Writer: Jeanine Parsch, 765-337-7047, jeanine@purdue.edu

Tags: Process & Cost Improvement (Lean) , Quality Services

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