JUNE 28 - JULY 2, 2020   •  Boston, MA
30 years of Care Transitions Across the Full Continuum

PP105 – The Impact of Structured Mulitfaceted Transition Management Roundtables- A Viable Solution to Breaking Barriers in Transitions of Care

Jun 29 2020
5:00 pm - 7:00 pm

PP105 – The Impact of Structured Mulitfaceted Transition Management Roundtables- A Viable Solution to Breaking Barriers in Transitions of Care

Effective  and efficient hospital wide throughput plays a significant role in the wellness of both the patient and the hospital system alike. Care planning that produces positive patient outcomes, improves patient experience, and decreases financial risks to the hospital system is a team effort. This is achieved in transition management rounds. The team consists of the Physician Advisor, Nurse Case Manager, Social Work Case Manager, Advance Practice Practitioner, Quality Program Manager,and Post Acute Care Liaisons. We discuss observation patients and patients who have length of stay of 3 days or more. The Case Manager provides a brief synopsis of how the patient presented to the hospital and the care plan. Barriers that impede care coordination are discussed, followed by creating a collaborative patient centric plan designed to improve the transition of care. An evaluation of the appropriateness of patient status is also discussed and needed changes are made at that time by the physician advisor. Prolonged and inefficient throughput can be attributed to delays in patient care, increased mortality, and increased financial burdens (Sanchez, Suarez, Asenjo, and Bragulat, 2018). This team approach with all professional disciplines represented allows us to effectively design and implement care plans and work to decrease barriers to patients accessing the next level of care. With the team collaboration that these rounds have facilitated, more patients are changed from observation status to inpatient status, observation hours have decreased  by 12.2% from 2018 through mid-September 2019. Overall communication has also improved between care team members and our patients, this allows for improved patient experience and outcomes.

reference-
Sanchez M, Suarez M, Asenjo M, Bragulat E. Improvement of emergency department patient

flow using lean thinking. International  Journal For Quality In Health Care. 30(4):250-256. doi:10.1093/intqhc/mzy017