A unique opportunity is available when caring for our patients and families experiencing end of life decisions. Authentic presence, listening, and problem solving empower our patients along their journey.

1. Caring Advocacy: Transition of Patients
from Hospital to Home/Next Level of Care
Lynn Eubanks, RN, BSN, Patient Care Coordinator SFO
Margaret G. Williams, RN COCSD SFO
San Francisco Kaiser Permanente – 2425 Geary Blvd., San Francisco, CA 94115

2. Caring Advocacy & Early Planning for
After-hospital Care
• Focus on “Caring Science of Nursing” to
increase patient’s understanding of transition
from hospital
• PCC Team assesses after-hospital needs – the
next Level of Care (LOC)
• PCC’s & Multidisciplinary team assists
patient/family in planning care & accessing
Continuum resources

3. Patient Care Coordinator (PCC )Team
• Coordinates patient transition from hospital
• Manages clinical utilization with InterQual – medical
necessity
• Partners with Multidisciplinary Team (physicians, RN’s,
SW’s, PT’s, pharmacy, etc.)
• Manages transition care

4. Why focus on Transitions now?
Impact to 2012 World Class Hospital Goals
4 | © 2011 Kaiser Foundation Health Plan, Inc. October 6, 2014 For internal use only.

5. Value ~ Caring Advocacy Embraces
• Right Venue of Care
• Timely Patient Care
• Coordinated Care

6. Implementing Caring Processes
Collaboration Is A Process
• Daily Bed Meeting
• Scripted communication between Pt. & family/Multidisciplinary
team members
• Frequent dialogue with Nursing Managers, Bedside RN’s
• PCC Team works with physicians/PCS partners
• “Discharge Planning/Admission Assessment” Form
• Early planning reveals barriers to discharge & facilitates
smooth transition

7. 7
K-SFO BED MEETING
| © 2011 Kaiser Foundation Health Plan, Inc. For
internal use only.

8. #1 Admission Assessment = Good Discharge
Planning
 Review all inpatient admissions to SFO
 Interview/assess patient/family within 1 day of
admission
 ID crucial points of discharge planning & partner
with patients/families to ID and assess needs,
resources, gaps (Human Needs Assistance)
 Document Anticipated Discharge Disposition (ADD)
 Document Expected Date of Discharge (EDD)
8 | © 2011 Kaiser Foundation Health Plan, Inc. October 6, 2014 For internal use only.

9. Starting with our initial
interview we focus on
both the “Cared-for” and
the “Care-givers”

10. #2 “Going Home” Assessment Tool & Script
 Introduced as a training tool in 2011
 Process now embedded in daily PCC practice
 Engages patient/family in planning for transition
 Develops Helping-Trust Relationship with patient/family
 White Board in patient room – ADD + EDD prepares
patient/family/hospital care team
10 | © 2011 Kaiser Foundation Health Plan, Inc. October 6, 2014 For internal use only.

11. #3 How We Help
 We are the “Care Coordination Navigators”
 Early/frequent assessment
 Identify barriers to discharge
 Streamline documentation & communication
 Coordinate intra-departmental participation
 We build patient/family confidence, decrease
discharge fatigue & reduce last-day hassle
11 | © 2011 Kaiser Foundation Health Plan, Inc. October 6, 2014 For internal use only.

12. Results
• Multidisciplinary Team growth
• Increased Multidisciplinary Team
communication
• Increased Patient Satisfaction
• Decreased Patient Day Rate (PDR)

13. Measuring Success: HCAHPS
92
91
90
89
88
87
86
85
84
1. During this hospital stay, did doctors, nurses, or other hospital staff talk with you about whether you
would have the help you needed when you left the hospital?
2. During this hospital stay, did you get information in writing about what symptoms or health problems
to look out for after you left the hospital?
13 | © 2011 Kaiser Foundation Health Plan, Inc. October 6, 2014 For internal use only.
Excludes OB/Pedi
HCAHPS Discharge Information Composite Results
83
Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12
% Top Box

14. 14 | © 2011 Kaiser Foundation Health Plan, Inc. October 6, 2014 For internal use only.

15. Lessons Learned
• Start transition planning within 1 day
of admission
• Communicate via authentic
interactions verbally and in writing
with patient and entire care team
• Document in HC: “Care Coordination
Navigator”
• Execute safe discharge plan
15 | © 2011 Kaiser Foundation Health Plan, Inc. October 6, 2014 For internal use only.

16. Follow through ~ ~ ~ Follow Heart
Caring Advocacy provides
the best discharge outcomes possible
16 | © 2011 Kaiser Foundation Health Plan, Inc. October 6, 2014 For internal use only.