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

PP203 – Transforming Lives by Individualizing Care: Developing a Person Centered Collaborative Case Management assessment Tool

Jun 30 2020
12:30 pm - 2:30 pm

PP203 – Transforming Lives by Individualizing Care: Developing a Person Centered Collaborative Case Management assessment Tool

 

Background:

     Health policy experts have identified poor care transitions as a major contributor to poor quality and waste. Inadequate care coordination, including inadequate management of care transitions was responsible for$25-45 billion in wasteful spending through avoidable complications and unnecessary hospital readmissions (Dreyer, 2012).

Literature Review:

     Inadequate care coordination as identified by researchers, including inadequate management of care transitions, was responsible for $25 to $45 billion in wasteful spending in 2011 through avoidable complications and unnecessary hospital readmissions (Robert Woods Foundation 2013). Individualizing care and the use of formalized assessment tool within the first 48 hours of hospital admission assists in tailoring transitions and discharge to patients, families and caregivers preferences and assists in overall satisfaction

Results:

Using data from the HCAHPS and Press Ganey Scores South Pointe Hospital was able to improve discharge experiences of patients attributed to involving the patient, family and caregivers in the transition and discharge process which begins on the day of admission and utilizing our CMA tool contributed to our improvement in patient satisfaction.

  • HCAHPS question: During hospital stay staff took my preferences, families and caregivers into account in making decisions related to my health care needs
    1. October 2018 target 56.9% actual 49.8% (43rd percentile)

                 2.  February 2019 target 56.9% actual 69% (99th percentile)

  • HCAHPS Care transitions domain

           1. October 2018 target 61% actual 49.8% (40th percentile)

                  2. February 2019 target 61% actual 61.4% (91st percentile)

  • Press Ganey information domain: Staff talked about help when I was discharged or left the hospital

            1. October-December 2018-83%

                   2. Jan-March 2019-85%