Learner Objectives
- Describe successful approaches that have been implemented to improve care transitions
- Develop necessary skills for driving improvement
- Improve the coordination of care through greater engagement of the cross-continuum team
Agenda -with PPT Presentations
(Agenda PDF here)Welcome and Set the Stage
Presenter: Paula Griswold, MA Coalition for the Prevention of Medical Errors; Lorraine Schoen and Pat Noga, MA Hospital Association - Presentation
Driving for Results in STAAR
Presenter: Pat Rutherford, Institute for Healthcare Improvement - Presentation
Session A: Engaging Patients and Families
Discuss strategies for partnering with patients and families to improve their experience of discharge from the hospital and coordination of post-acute care.
Presenter: Sarah Moravic, Beth Israel Deaconess Medical Center - Presentation
Facilitators: Rebecca Steinfield, Paula Griswold, Linda Kenney
Session B: A Holistic Approach to Discharge Planning
Discuss how to better plan for and coordinate follow-up care for the resident's transition from skilled nursing to home.
Presenters: Patricia Sherman, and Angela Taveras, Life Care Center of West Bridgewater - Presentation
Facilitators: Lorraine Schoen, Helen Magliozzi, Cheryl Pacella
Session C: Learning from Defects
Learn about how one organization used a multidisciplinary case conference, with family input, to understand root causes behind readmissions and to identify ways to operate more effectively.
Presenters: Randi Berkowitz, Hebrew SeniorLife - Presentation
Facilitators: Kate Bones, Pat Kelleher, Saranya Kurapati
Session A: Creating an Effective Cross-Continuum Team
Learn how one team has effectively brought together broad representation on their cross continuum team to work together in co-designing key care transition processes.
Presenter: The Emerson Hospital Cross Continuum Team - Presentation
Facilitators: Kathy Foss, Saranya Kurapati, Helen Magliozzi
Session B: Using Data to Drive Improvement
Learn how to better use your data to influence others and better drive your quality initiatives.
Presenters: Rebecca Steinfield, IHI - Presentation
Cathleen Bachert, Cape Cod Hospital - Presentation
Facilitators: Pat Noga, Cheryl Pacella
Session C: Working Session on Medication Reconciliation Across the Continuum
Join us for a working session to identify failure modes, discuss improvement ideas, and plan for testing changes that improve medication reconciliation across care settings in your community.
Facilitator: Paula Griswold, Lorraine Schoen, Pat Kelleher
Session A: Engaging Physicians
Understand the frame of reference and the challenges facing physicians and learn how to better engage them in efforts to reduce readmissions.
Presenters: Julius Yang, Beth Israel Deaconess Hospital; Soma Stout, Cambridge Health Alliance; Cheryl Pascucci, Commonwealth Care Alliance ; John Pastore, Steward Health Care System; Bruce Auerbach, Sturdy Memorial Hospital - (No Powerpoint Presentations)
Facilitators: Gail Nielsen, Paula Griswold, Lorraine Schoen, Kathy Foss
Session B: A Nursing Education Curriculum for Improving Care Transitions
Provide input into the Care Transitions Education Project nursing curriculum for improving care transitions. You can assist in creating the most useful final product for our work based on your experience on your STAAR team.
Presenters: Jena Adams and Kelly Aiken, Care Transitions Education Project; Tamalie Cole-Poklewski, Cooley Dickinson Hospital; Karen Rousseau, American International College - Presentation
Facilitators: Helen Magliozzi, Cheryl Pacella, Chris Chue
Session A: The Role of the Emergency Department in Care Transitions
Learn about ways to involve the emergency department in reducing readmissions and improving care transitions.
Presenters: Cherelyn Roberts, Elizabeth Saykin, Challis Krulewitz and Laura O'Connor with Holyoke Medical Center;Diane DeMatteo with Holyoke Health Center - Presentation
Facilitators: Paula Griswold, Rebecca Steinfield, Pat Noga
Session B: Coordinating the Efforts of ASAPS, Care Transitions Coaches, and Home Health Care
Identify strategies for better coordinating needed services for at-risk elders and avoiding new fragmentation of care
Presenters: Janet Liddell, Saints Medical Center; Mary Wiggins, Lawrence General Hospital; Lori O'Connor, Elder Services of Merrimack Valley; Patricia Finoccharo, Home Health VNA - (No Powerpoint Presentations)
Facilitator: Kate Bones, Lorraine Schoen, Cheryl Pacella, Pat Kelleher
Session A: Reliable Implementation and Scale Up - The Foundation for Sustainability and Spread
Utilize strategies for designing reliable processes on the pilot units and develop the infrastructure and plan for spreading successful changes.
Presenter: Patricia Rutherford, Institute for Healthcare Improvement; Gail Nielsen, Iowa Health System - Presentation
Facilitators: Rebecca Steinfield, Saranya Kurapati, Pat Noga
Breakout B: Developing a Work Plan for Improving End of Life Care
Participate in a working session to outline the key steps for improving end of life care across your community
Facilitators: Jane Pike Benton, Paula Griswold, Pat Kelleher - Presentation
Breakout C: Creating a Safe and Effective Transition into Skilled Nursing and Reducing Transfers to the Hospital
Fine-tune the hospital-to-SNF and SNF- to-hospital transfer processes to ensure key information is communicated and used effectively to care for the patient.
Presenters: Jason Marchi, Maristhill Nursing and Rehab Center - Presentation
Paul O'Connell, Beaumont Rehabilitation and Skilled Nursing Center - Presentation
Facilitators: Kate Bones, Kathy Foss, Helen Magliozzi