Provide two examples, with supporting evidence, of nurses' involvement in interprofessional collaborative practice that ensures care coordination and continuity of patient care.  

Example 1 -Readmission team improves communication and care coordination through interprofessional collaborative practice. 

In 2012 the hospital developed a readmission team whose responsibility was to address the quality strategic aim of reducing avoidable hospital readmissions by 25% below the national rate. This team has been highly successful. The original group consisted of Social Workers, Pharmacists, Nurses, Physical Therapists, Dieticians and Respiratory Therapists. The group meets every Thursday and discusses specific patients that have been readmitted. The group looks for trends in the readmission data and identifies opportunities for improvement.

Over the past 2 years they have identified opportunities to partner with other care providers in our community such as:

• Care Managers, who began attending re-admission team meetings in July 2013. This collaboration supports continuity of care from the hospital to home setting and identifies potential ongoing issues that can be addressed at follow up visits. Changes in medications and concerns raised during the hospital visit can be reviewed, with the goal of preventing avoidable readmissions.
• Representatives from the local Developmental Disabilities Services Organization (DDSO) attended a meeting to review several residents that had multiple readmissions to identify any opportunities for better information transfer.
  
  

Our primary care partners have nurse care managers who routinely participate in our meetings. They bring their laptop computers and this allows them to put notes directly into their electronic medical record. These notes are available for the providers to review at the next follow up visit. One particular area of opportunity that was identified was end of life discussions and care planning. At Thompson we have a hospitalist medicine group that manages the majority of the medical patients. They work 7 days (or nights) in a row and then switch out. Often they are meeting patients during a particularly difficult time. They have identified that end of life care discussions can be challenging when meeting a patient and/or family for the first time. Having the RN care managers at our meetings has enabled us to identify patients for whom an end of life discussion is appropriate. Indeed our most frequent reason for readmission is that palliative/end of life care was not addressed. They are able to follow up with the provider and the patient during their post hospital practice visit (see Exhibit EP5.1). In addition they bring information that we would otherwise not have access to that helps us to identify other opportunities for improvement.

Exhibit EP5.1 Excerpt from MEDENT electronic medical record from a patient discussed during re-admission team meeting with Care Manager from a local Primary Care Practice.



In 2013, we identified that a specific trend concerning developmentally disabled residents of the DDSO system. We have a large population of DDSO homes locally and we noted that a small number of residents of these homes were being readmitted frequently.
As a result a meeting was planned with the leadership from the local DDSO to discuss our joint working to ensure that there was good continuity of care and identify any opportunities to improve communication, care coordination and ultimately reduce readmissions. The readmission team met with 3 members of the leadership of the DDSO, including their Chief Nursing Officer, Mary Jolley on September 9th 2013. Meeting Discussion:

Case Reviews:

• 6 specific patients with high rates of readmission were discussed.
• The DDSO team discussed what they were doing to prevent these readmissions as well as looking into higher level of care homes for certain residents.
• Level I Homes: High functioning individuals without 24x7 nursing coverage.
• Level III Homes: 24 hour nursing coverage (RN or LPN) with higher ratios of residents to caregivers.

Advanced Directives:

• If there is the need to move to DNR/I best to initiate in the hospital or with PCP after discharge. Difficult for caregivers to initiate.

Collaboration and Coordination:

• Discussed the triage process for after hours that results in taking resident to the ED.
  
  

Another meeting is planned for September this year.

Overall our readmission team has continued to ensure best practices are instituted and care coordination and collaboration are the hallmarks of our program. In 2013 our overall readmission rate for all payors in the hospital was 9.4% and for the first quarter of 2014 the rate is down to 8.2%. Our program continues to develop and as we identify new opportunities for enhancing care coordination across the different care settings.

Example 2-Care Coordination through the development of an Orthopedic Service Line

In early 2014 the Orthopedic Service Line Committee set a goal to become the first area at FF Thompson to receive The Joint Commission Gold Seal of Approval focused on disease specific care or the orthopedic joint replacement patients.

The Orthopedic Service Line Committee is an interdisciplinary team lead by our Service Line Coordinator, Stephanie Friel, RN. The team consists of clinical nurses, rehabilitation services associates, medical social workers, physicians, pharmacists, dietitians and representatives from our short term rehabilitation unit. the operating room and administration.

The first area of focus was to establish standards of practice for all of the disciplines providing care to the patients. These standards were based on evidence-based best practices and were individually approved at the committee level. For the nursing standards the unit based council reviewed the Lippincott procedures manual and elected to use those as the evidence based standards for our practice (see Exhibit EP5.2- EP5.13).

Exhibit: EP5.2 SWTJRClinicalGuidelines-TH3-2014.pdf

Exhibit: EP5.3 ProphylacticAntibioticsForSurgery.pdf

Exhibit: EP5.4 DVT prophylaxis Ortho.pdf

Exhibit: EP5.5 Clinical Guidelines for RT for Patients Undergoing.pdf

Exhibit: EP5.6 anesthesia practice guidelines.pdf

Exhibit: EP5.7 Ortho Service LIne Procedure.pdf
 

Once approved the standards were disseminated through each department for review and educational purposes.

Based on the nursing standards of practice two priority areas were identified: Circulation Motion Sensation (CMS) checks and pain assessment. The best practice for CMS checks was every two hours which was not our previous standard. Pain assessment, per the standard was required every four hours for the first 48 hours. The unit based council suggested that audits occur to ensure compliance, and Stephanie has been conducting these audits and posting the results for the clinical nursing staff to review.

For each nursing department binders have been created with all of the standards in place. Although, we have a primary unit that cares for the majority of total joint replacements approximately 5% annually require management either on a telemetry unit or in the ICU. This process ensures all clinical RN's caring for the total joint patient understands the standards of care and the interdisciplinary involvement. We have ensured continuity of care throughout the organization with evidence based standards of care for the orthopedic population.

Exhibit: EP5.7 Ortho Sub-Committee 01.15.14 Minutes

Exhibit: EP5.8 Ortho Service Line 01.29.14 Minutes

Exhibit: EP5.9 Ortho Sub-Committee 02.06.14 Minutes

Exhibit: EP5.10 Ortho Sub-Committee 02.19.14 Minutes

Exhibit: EP5.11 Ortho Sub-Committee 03.06.14 Minutes

Exhibit: EP5.12 Ortho Sub-Committee 03.19.14 Minutes

Exhibit: EP5.13 Ortho Sub-Committee 04.30.14 Minutes