{"id":77,"date":"2016-04-26T10:25:03","date_gmt":"2016-04-26T14:25:03","guid":{"rendered":"http:\/\/blog.camberry.ca\/?page_id=77"},"modified":"2016-05-25T12:13:04","modified_gmt":"2016-05-25T16:13:04","slug":"7-day-followup","status":"publish","type":"page","link":"https:\/\/blog.camberry.ca\/?page_id=77","title":{"rendered":"7 Day Followup"},"content":{"rendered":"

Seven-Day Post-Hospital Discharge Follow-Up Rate for Selected Conditions<\/u><\/strong>
\n<\/u><\/strong>Percentage of patients or clients who see their primary care provider within 7 days after discharge from hospital for selected conditions
\n<\/u><\/strong>Direction of Improvement: increase<\/em><\/p>\n

\"7dayfollowup\"<\/a><\/p>\n

Summary\/Analysis<\/strong><\/p>\n

Recurring trend of need to educate patients of importance to communicate hospital visits to care provider. As well as increasing communication between hospital and FHT, this is often complicated by IT barriers to accessing information.
\nOften commented that the numerator of this indicator does not include contact with healthcare providers other than physicians so may not be very accurate in measuring care received.<\/strong><\/p>\n

Effectiveness<\/strong>:<\/p>\n

Bancroft <\/span>? Promoting integration with the use of the Health Links System Navigator RN and Data Management Coordinator worked well to improve outcomes<\/p>\n

Trent Hills <\/span>? focussing on a proactive approach of tracking discharges from hospitals and booking follow up appointments -> actively calling patients to book appointments<\/p>\n

Aurora ? Newmarket:<\/span> Participation in the EPIC (Expanding Paramedicine in the Community) program may greatly improve this measure by providing care at home for patients with chronic conditions.<\/p>\n

Health For All:<\/span>? Unspecified change idea resulted in little improvement for this measure<\/p>\n

Southlake:<\/span> team members who follow up on discharge patients (nursing and social work team). Seeing success in receiving hospital data regarding patient discharges.<\/p>\n

Recommendations:<\/strong><\/h2>\n

Ideally, access to hospital admission\/discharge information is pertinent to improve this measure by taking a proactive approach to booking follow up appointments. Identifying specific team members responsible for follow up has been effective as well.<\/p>\n

 <\/p>\n

DETAILS <\/strong><\/p>\n

Bancroft<\/u> ?????57.00 ?> 75.00<\/em><\/p>\n

    \n
  • Patient education about informing primary care of admissions and discharges<\/li>\n
  • Develop and test processes for identifying and recording patient admissions and discharge and identifying patients that require follow-up visit in a timely fashion
    \n-> continue working with Health Link in promoting integration<\/strong><\/p>\n
      \n
    • Implementation of Health Links System Navigator RN and Data Management Coordinator greatly improved outcomes for Health Link patients <\/em><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n

      -> work with hospital to receive reports in a timely manner<\/strong><\/p>\n

      Trent Hills<\/u>?????? 66.00 ?> 67.00 <\/em><\/p>\n

        \n
      • Be more proactive in booking discharge apt.?s<\/li>\n<\/ul>\n

        -> ?Devise a proactive tracking system for discharges from hospitals other than CMH, doing TDIS downloading of discharge summaries to prompt phone calls to patients<\/strong><\/p>\n

          \n
        • Booking clinics called patients, majority of patients like proactive approach, some declined apt., felt it was unnecessary, inconvenient, too difficult to get too <\/em><\/li>\n<\/ul>\n
            \n
          • Continue to make post discharge apt.s a priority
            \n-> educate staff and clinicians on importance<\/strong><\/li>\n
          • Improve patient access
            \n-> same as timely access ideas above<\/strong><\/p>\n
              \n
            • two year goal, didn?t anticipate seeing changes yet <\/em><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n

              ?<\/strong><\/p>\n

              Haliburton Highlands<\/u>??????? 77.00 ?> 63.00<\/em><\/p>\n

                \n
              • Complete 3 day post discharge phone assessments
                \n-> develop procedure and tool for phone call survey with FHT and hospital partners<\/strong><\/li>\n
              • Ensure apt. been made for follow up with PHCP within 7 days or earlier as required
                \n-> review hospital discharge process with hospital discharge planner<\/strong><\/li>\n
              • Work with hospital partners to develop discharge information pathway for identified population -> meet with hospital partners and review current state of information exchange to identify opportunities<\/strong><\/li>\n<\/ul>\n

                ?<\/u><\/p>\n

                West Durham<\/u>????? 26.00 ?> 24.00 <\/em><\/p>\n

                  \n
                • Enhance patient understanding of need to communicate with primary care post discharge -> additional question added to patient experience survey<\/strong>\n
                    \n
                  • Dedicated System Navigator\/Case Manager is most effective way to fill this gap for patients -> requested MoH funding for this in 2014\/15 to lead this measure and change initiative (since been unsuccessful for funding) <\/em><\/li>\n
                  • Tasked Pharmacist and Program Manager to develop another process<\/em><\/li>\n
                  • Initially, determine if patients are in fact aware of requirement to follow-up with care provider -> additional survey question for this<\/em><\/li>\n
                  • Stated that this data not accurate because it does not capture patients seen by NP, as well many patients booked for 2 week follow up with internal medicine clinics so do not feel need to book another apt. within 7 days<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n

                    Aurora ? Newmarket FHT:???? 34.00 ?> 47.00<\/em><\/p>\n

                      \n
                    • With current barriers with IT and communication with hospital, difficult to know when a patient has been discharged from the hospital<\/li>\n
                    • Plan to be able to access HRM which will allow us to have more timely notification of a patients discharge -> enable us to have patients contacted to initiate a post discharge follow up with the patient<\/li>\n
                    • Can assess situation and decide whether an OT visit or physician house call is warranted<\/li>\n
                    • The EPIC program that is currently being implemented will help ensure that patients are seen within 7 days of discharge, as well it is the hope that the program will completely deter these patients from being admitted by creating more access to care<\/li>\n<\/ul>\n

                      Health For All FHT:???? 23.00 ?> 24.00<\/em><\/p>\n

                        \n
                      • Increase timeliness of office visits post-discharge from hospital for certain chronic conditions (based on CMG data from Ministry)<\/li>\n<\/ul>\n

                        Southlake FHT: ???0 ?> 56.00<\/em><\/p>\n

                          \n
                        • Collect and analyze info on inpatient hospital admissions and discharges<\/li>\n
                        • Follow-up with patients after discharge from the hospital for all conditions including selected conditions (based on CMGs)<\/li>\n
                        • Increase collaboration with the hospital and local community to ensure discharge data is obtained within a timely manner\n
                            \n
                          • Our team currently collects discharge data from the Horizon Physician Portal. Our QIDSS created an excel file that highlights those who have been discharged from our local hospital ? Southlake. We have our nursing and social work team call patients who have been discharged and follow-up on their care. This strategy has improved our baseline rate from 18-56 percent over this last year.<\/li>\n
                          • this performance rate is based on only new market location and does not include satellite sites, next years? QIP will include all locations<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n

                             <\/p>\n

                             <\/p>\n","protected":false},"excerpt":{"rendered":"

                            Seven-Day Post-Hospital Discharge Follow-Up Rate for Selected Conditions Percentage of patients or clients who see their primary care provider within 7 days after discharge from hospital for selected conditions Direction of Improvement: increase Summary\/Analysis Recurring trend of need to educate patients of importance to communicate hospital visits to care provider. As well as increasing communication […]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":85,"menu_order":2,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-77","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/blog.camberry.ca\/index.php?rest_route=\/wp\/v2\/pages\/77","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blog.camberry.ca\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/blog.camberry.ca\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/blog.camberry.ca\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/blog.camberry.ca\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=77"}],"version-history":[{"count":5,"href":"https:\/\/blog.camberry.ca\/index.php?rest_route=\/wp\/v2\/pages\/77\/revisions"}],"predecessor-version":[{"id":95,"href":"https:\/\/blog.camberry.ca\/index.php?rest_route=\/wp\/v2\/pages\/77\/revisions\/95"}],"up":[{"embeddable":true,"href":"https:\/\/blog.camberry.ca\/index.php?rest_route=\/wp\/v2\/pages\/85"}],"wp:attachment":[{"href":"https:\/\/blog.camberry.ca\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=77"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}