Tips

Make Care Safer by Reducing Harm Caused in Delivery of Care.
Assistant Director of Nursing continues to lead education on fall prevention, policy and procedure review and revision for Adverse Drug Events; hypoglycemic medications have occurred, reduce avoidable readmissions related to care coordination, implement safeguards within the patient care home environment to assure a safe transition from acute care including home health, hospice, outpatient services, home health aides, medication management.

Strengthen Person and Family Engagement
Patient Experience Coordinator position was created in late 2017.

Promote Effective Communication and Coordination of Care
Bringing together Patient care team weekly and consistently with our ACO Nurse, Home Health Nurse, and Nursing Home Representative for discharge planning with a goal to prevent readmission. ACO Care Coordinator attends daily hospital rounds and weekly Home Health Meetings to ensure comprehensive care for our patients during hospital discharge and when
they need more care.

Promote Effective Prevention and Treatment of Chronic Disease
ACO & PCMH – Transitional Care Management (working with the hospital to get Medicare discharged patients to their appropriately timed follow up appointment with needed medications and services, working on a process for phone calls to be made to all of our ER and Convenient Care patients within 2 days of the visit). In the makings of Care Coordination Management program to work with Medicare patients with 2 or more chronic conditions, to help them better manage their conditions (arthritis, asthma, diabetes, hypertension, heart disease and osteoporosis) through support, education, coordinating of care to specialists, primary care, 24/7 emergency care medication review, and phone call check- ins.

Work with Communities to Promote Best Practices of Healthy Living
Brought in multiple services to this area, Care-a-Van use for medical needs. One process in the works is to include tracking our patients that were transferred out for services and ensure that they are getting appropriate follow up care. Medicare Annual Wellness Visits is our Care Coordinators main project at this time.

Make Care Affordable and Accessible 
More specialties have been brought in for local outpatient services including telemedicine, and continue with Convenient Care as well as Emergency room open 24 hours a day. Wellness visits and follow up visits remain vital in decreasing inpatient stays.