Clarke County Hospital’s Community Care Coordination planning started in 2014 after a team attended an Iowa Healthcare Collaborative conference in Des Moines. The team was inspired by hearing how other hospitals were using resources, such as nurses and ER staff, to visit patients after discharge in the home setting.
“We knew we wanted to implement this best practice at Clarke County Hospital to better serve our patients,” Melanie Boyd, MHA, RN at Clarke County Hospital mentioned when discussing this effort. “We used HEN resources to decrease readmissions to drive our transitions program.”
The team implemented the STARR tool, follow-up appointments made at discharge, improving communication with long-term care and home care organizations, and teach-backs. This effort was initiated by Dr. Julia Jenkins-Medical Director, Vicki Irvin-Chief Clinical Officer, Christie Sposeto-DON, Norene Campbell-Discharge Planner, Robin Linskens-Social Worker and Vicki Lande RN.
The planning process started with what the team wanted to accomplish at the first meeting, this included introducing the Unity Point Physicians and their staff to the surrounding medical services available to Clarke County Hospital patients, investigating the process for referrals to different services, and improving the transition of care to those services. The meeting was held in December 2014 at the Clarke County Hospital administration building for a lunch and learn. The team wanted to make sure this was not a onetime meeting, they worked toward meeting with these and other community services in other counties being utilized by our patients, on a quarterly basis discussing ways to improve the transition of care for the patients in the community.
Surrounding services included: Unity Point Physicians and their staff, Unity Point at Home & Hospice, Southern Hills Specialty Care & Care Initiative Hospice, Homestead Assisted Living, Public Health, and HCI. Two people from each service were invited to the first meeting.
Each service spoke to meeting attendees about the services they provide, the issues they were having with the referrals, and suggested corrections toward the referral process from Clarke County Hospital. Notes were taken and the changes were introduced to staff and implemented.
Currently members now include: Medical Director, Erin Dykes-CCO, Melanie Boyd CXO, Liz Jones-DON, Robin Linskens-SW, Vicki Lande-Discharge Planner, Zach Woods-Health Promotions & Emergency Preparedness Coordinator, Michele Evink-Pharmacist, & the Physicians, Community Pharmacies x3, Hospice x2, Home Care Agencies x4, Nursing Facilities x3, Public Health Agency x1.
Since the first meeting, the team holds quarterly meetings, discusses issues with transitions, hold educational events, and have added other county services to the team.
Currently the team is working on improving the PTA (Prior to Admission) medication process between clinic, pharmacy, and Clarke County Hospital. We also plan to implement a medical directory with the team member’s services, address, and phone number. Our goal is to introduce the medical directory at the next meeting in October, disperse them with the admission packets and at events in the community.
-Writing Credit: Clarke County Hospital