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Tool 1. 2: Forming a Cross- Continuum Team. Purpose: To advise and assist with the formation of a cross- continuum team. Description: This tool explains the benefits and process of building a cross- continuum team and offers a template for inviting partners to join it. Staff: Quality improvement leadership, cross- continuum team. Time required: N/A; tool used for informing how to convene this team of variable size.
By definition, a transition involves a . Remember that the best transition out of your setting is only as good as the reception into the next setting of care.
Forming a cross. Some of the immediate benefits include: Declare to your referral partners your organization's readmission reduction goals. Describe the range of efforts your organization is implementing to reduce readmissions.
Understand what your cross- setting referral partners are doing to reduce readmissions. Understand what information your receivers need to facilitate a safe and stable transition into their setting to avoid a readmission. Form and strengthen multidisciplinary relationships among providers who share the care of common patients (putting a face to a name). Identify partners that will help your hospital achieve quality, satisfaction, and/or cost goals. Forming a cross. Acknowledge that not all possible partners are at the table, and allow the group to expand naturally over time. Once you start hosting cross- continuum team meetings, other providers will want to be included.
An example email/letter of invitation for new members of your cross- continuum team is on the following page. Keep it simple, and send the emails today. Use Tool 5, the Cross- Continuum Inventory Tool, to identify providers and agencies to invite. As you expand your readmission reduction efforts to include adult Medicaid patients, consider reaching out to the following: Medicaid managed care organizations. Medicaid behavioral health carve- out plans. Medicaid agencies, especially in a fee- for- service market.
Behavioral health providers, community mental health, crisis teams. Substance abuse treatment providers. Home health agencies that serve high- volume Medicaid and/or behavioral health patients.
Physician practices that serve high- volume Medicaid patients, including community health centers. Social service agencies, including those that provide social work services. Elder service agencies, including those identified as aging and disability resource centers. Pharmacies that provide bedside delivery and/or medication counseling services. Adult day health programs.
Local emergency departments that share the care of common frequent users. Community Partnership Meeting. Our aim is to reduce readmissions by .
We hope to foster an active and highly productive community- based coalition of providers working in alignment toward a common goal of safe transitions in care for our shared patients. Please join us. Please come for all or part of the meeting. If you are not available, we would welcome a colleague from your organization. We look forward to working together toward the improved care of our patients in . Please do not hesitate to contact me with any questions. Kind regards, . Productive cross- continuum collaboration requires fostering a team culture of engagement, commitment to shared goals, transparency, and shared learning. If you are convening.
Experience suggests that a trusting, collaborative environment of open feedback, shared problem solving, and improvement can be established within the first two or three regular meetings of a cross- continuum team. Establishing a shared action agenda is essential for engaging sustained participation in cross- continuum team efforts and for converting good intentions into demonstrable improvements in transitions between settings and providers. There are numerous potential actions for a cross- continuum team; the specifics are determined by your local partnerships, your high- risk populations of interest, and the strengths of the change. Your cross- continuum team can. Assigning responsibility for leading, coordinating, or reporting at future meetings engages a diverse membership in coproducing the agenda and work of this team. The last part of this tool is an example from the field of a cross- continuum team agenda and minutes.
Domain. Action. Person(s) Responsible. Date Due. Causes of Readmissions. Overview of recent papers or presentations about readmissions Quarterly. Discuss recently readmitted patient to identify opportunities for improvement Every meeting. Discuss hospital- specific readmission trending data Every meeting. Community Resources and Capabilities.
All skilled nursing facilities complete INTERACT . She discussed how the medication reconciliation process is a main focus of the transition of care team.
The group discussed opportunities to strengthen relationships to improve transitions of care. Health Information Exchange. HIE update. They are waiting on a quote for needed equipment to do this. XX reported physician practices that are partnered with XX are also connecting with the local HIE.
She stated that 2. HIE. XX will call the vendor to assist with getting the needed quote. Readmission Data. Overall findings revealed that many patients are readmitted from SNF facilities due to family members insisting residents are sent to hospital when their condition changes. The group discussed possible ways to talk with families to help them understand options for residents versus immediately sending to hospital. XX also discussed the possibility of using Telehealth communication systems in SNF's Improved Handoffs. Home Health Electronic Orders and Medication Reconciliation Form to SNF's XX reported she will set.
XX and Hospital IT staff to discuss ways to get an electronic signature on the Home Health orders and to streamline the medication reconciliation forms with appropriate MD signatures. XX and Dr. XX will report at next meeting. Meeting adjourned at 8: 3. Next meeting scheduled for XXX.
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