What you need to know about Care Delivery

What you need to know about Care Delivery at Temple 2016 TUHS House Staff Orientation Lee Buttz, MD, MBA Maryteresa Mintz, BSN Kevin Banks, RPT Betty Craig, DNP, CRNP

Care Delivery Team Review Assessments and Roles of: 1. Physician 2. Nursing 3. Physical Therapy 4. Case Management 5. Social Work And how they all coordinate as a TEAM in providing Safe, Timely, Effective, Efficient, Equitable, and Patient-Centered Care

Physician Role • Clinical assessment, treatment plan, and documentation of care • Medication reconciliation • Patient and family education • Transitions of care • Work rounds (teaching rounds) • Multi-disciplinary rounds – Patient Centeredness Care Coordination

Accountable Care Unit (ACU) Model Each unit is “geographic” and has: • Unit Based Medical Director (UBMD) who has oversight of and accountability for unit • • • Efficiency of care Patient throughput Decreasing variation Use of clinical care guidelines Support of patient safety and quality initiatives • Partnered management with nurse manager/UBMD and structured multidisciplinary rounding

Department of Nursing

Telemetry & Pulse Oximetry • Two classifications for telemetry – Class I (e. g. a-fib, a-flutter, certain medications) • If the patient needs to be transported, he/she must be on a cardiac monitor and accompanied by nurse or doctor (or both) – Class II (e. g. other diagnoses requiring monitoring) • The patient can be transported off telemetry without a nurse or doctor • All patients requiring telemetry will have IV access • Pulse Oximetry: – Verify the physician order for continuous pulse oximetry – The order must include acceptable range for saturations

Duration of Telemetry • Patients eligible for removal of telemetry monitoring will be reviewed at shift report – Criteria for removal have been established under the direction of the Cardiology Medical Director • If a patient meets criteria for removal after 48 hours on telemetry, then an order must be obtained to discontinue telemetry • House staff/resident will be notified – Attending physician has the option of reordering telemetry

Falls Prevention • Any patient designated Low Risk or High Risk is placed in the Fall Prevention Program - Morse Scale used to assess fall risk • The yellow armband (At Fall Risk) is placed on the same arm as the patient ID band • A Fall Risk Magnet is placed by the patient name on the locator board outside the patient’s room and on the door frame. • Interventions: – Use of low rise bed and or bed alarms – Assure assistance and supervision are provided with elimination, transfers and ambulation – Provide patient/family education – Recommend referral to PM&R for safe ambulation and transfer techniques

What happens if a patient does fall? • A Midas Incident/Event report must be entered. It needs specific information about the fall: Where, when, how, and whethere is injury? • Post Fall Assessment to be completed by the team • Falls are tracked and trended through Midas • The data is used to help us improve care

Close Observation Level 11: 1 Supervision-Suicide Precautions Patient who is an immediate threat to self: Staff must be within arm’s length of patient-including when in bathroom Level 2 Field of Vision/Visual Observation Patient danger to self or others or at risk for elopement: Staff must be in same room/area with visual contact with patient at all times. 2: 1 observation permitted Level 3 Enhanced Safety Observation Patient has delirium/dementia without violent behavior (may have impulsive behavior requiring more frequent observation): Staff must observe whereabouts, behavior, and patient condition every 30 minutes Level 4 Fall Precautions Morse scale to identify fall risk: Staff must observe whereabouts, behavior, and patient condition every 60 minutes. Notify RN if you assess any changes in patient’s mobility.

When and Why Should Physical Therapy be Ordered? • Is the patient at his functional mobility baseline? • Will medical treatment alone restore the patient to his baseline level? • Have there been attempts to mobilize the patient prior to therapy referral • Is patient able to participate in therapy? • Do you plan to transfer to a SNF or Rehab within the next 48 hours for PT services?

More about PT PT is contraindicated if: • • • Spine not cleared from trauma/METS X-rays/MRI pending No clear Weight Bearing status Patient with BEDREST activity orders Hg. B <7 INR > 5 PT is not necessary if: • • • Safely discharging home Want home PT for endurance or safety check Want outpatient PT for chronic issues Patient is baseline functionally Want a walking pulse ox

Other PM&R Services Occupational Therapy: Upper extremity dysfunction Hand/arm/shoulder splinting Splint, boots, shoes Activities of Daily Living dysfunction Acute Rehab assessment Speech Pathology Services: Diagnostic and therapeutic services for. Dysphagia Speech-Language dysfunction Cognitive Impairments Voice Disorders Mobility Aides: Trained aides to enhance patient mobility. Prevent patient debility that can cause secondary complications Physical Medicine and Rehabilitation: Consider early consult for musculoskeletal related issues or need for inpatient rehab.

CLINICAL RESOURCE MANAGEMENT DEPARTMENT Primary functions • Coordinate a safe and timely discharge plan • Monitor and decrease length of stay • Secure reimbursement for care • Collaboration with the team • Daily Accountable Care Unit interdisciplinary rounds

What is needed from you? • H & P MUST be in the medical record for all members of the team to begin their work • Document patient’s contact numbers in the H & P if you interview care giver/community representative • Clearly documented plan of care • Participation in unit based rounds • Forms and prescriptions completed timely • Communicate, Communicate

How we can assist you? • Case Managers and Social Workers can assist you with developing the plan for a safe transition to after care • Consult with team to determine appropriate level of care for transition • Available as a resource to you and team

When to consult Social Worker • Patient incapable of decision-making • No next of kin information • Social Work to assess provision of resources in the community to local health district and public welfare office • Suspicion of Domestic Violence, Child or Elder Abuse • Patient admitted with a psychiatric involuntary (302) or voluntary (201) need for continued psychiatric treatment when medically stable • Patient has active drug or alcohol issues • Assistance in placement of homeless patients

Case Management- Discharge Planning Considerations Home Care • Visiting Nurse • PT • IV Therapy • OT • Speech • Home care aide • Home Hospice Skilled Facility Acute Rehabiltation • Needs qualifying • PT needs diagnosis • Wound Care • Insurance • Wound Vac authorization • IV antibiotic therapy • PM&R team will • Inpatient Hospice provide physical, • Needs insurance authorization occupational, and speech therapies Long Term Acute Care Hospital (LTACH) • Daily Physician Assessment • Ventilator weaning • Complex wound care

Discharge Coordination • Special Circumstances: Chronic Dialysis – Skilled facility placement must be coordinated with the dialysis Social Worker – Patient agrees to hemodialysis site and Skilled Nursing Facility • Insurance authorization must be obtained • Patient medically cleared for transfer is documented • Final arrangements made, time of transport communicated • Transfer orders complete before time of discharge

Summary • Temple patients are complex! • Care delivery requires a multidisciplinary approach and great teamwork • Take advantage of your Temple Team: Everyone is here to help you provide safe, timely, efficient, effective, equitable, and patient-centered care • Welcome to your TUHS experience!