As a provider, there are some key tools available to you to ensure safe care transitions for your patients. There are also tools that you can encourage your patients to use.

The "Takeoff" Checklist  One way to reduce unnecessary readmissions is to redesign hospital discharge processes to support self-management among patients and families and to assure coordination with post-hospital care providers and practitioners.  Through the Stepping Stones Project, St. Joseph Hospital in Bellingham, WA is testing a redesigned discharge process with a patient “takeoff” checklist. The process and checklist seek to assure that the following perspectives are addressed:

• Information with understanding:  assure that the patient/family understand the diagnosis and the discharge plan, and that the patient’s primary care and/or specialty physicians are notified that the patient is being discharged.
• Red flags/danger signals:  assure that the patient/family understand what signs or symptoms might signal a worsening condition, and what to do.
• Medications: confirm a medication plan with the patient/family, including reviewing each medication’s purpose, how to take it correctly, and side effects to watch out for.
• Follow-up care:  provide the patient/family with a list of follow-up services that need to be scheduled or completed, including: primary care/specialist physician follow-up; outpatient lab, radiology, or other tests to be scheduled; and pending results of tests completed during hospitalization.

Personal Health Record

A personal health record is a powerful tool that allows patients to organize, store, and keep track of health information. Health information that could be stored on a personal health record include: medications, immunizations, diagnoses, hospitalizations, surgeries, allergies, reactions to medications and health indicators such as blood pressure, cholesterol, and blood sugars.

One of the primary goals of the Stepping Stones project is to encourage everyone to use a personal health record.

• Start using a personal health record for yourself and encourage your patients to use one. Talk with them about which information to include. Learn more about the use of personal health records.
• The Shared Care Plan is an electronic health record that was developed in Whatcom County). It is free, safe, secure, and can be accessed from any computer with internet access. There is also a paper version available.
  
  

Transition Coaching

An exciting component of the Stepping Stones project is to provide coaching to patients prior to, and shortly after being discharged from St. Joseph Hospital or a skilled nursing facility in Whatcom County. The primary role of the coach is to empower the patient and/or caregiver to take a more active role during healthcare transitions, and to develop lasting self-management skills. The coach supports patients over a four-week period that includes a facility visit, one home visit, and three follow-up phone calls.

• Learn more about the powerful impact of using of care transitions coaches
• Contact us to become a coach, or
• Refer one of your patients to a Stepping Stones coach.

(Our training and coaching services are only available in Whatcom County).

Medication Self-Management

Effective management of one’s medications and having a list of all medications in one place and available to all caregivers and providers is important…especially during transitions of care. Medication self-management is one of the four pillars of the Care Transitions Intervention. Furthermore, medication reconciliation (the act of making sure that a patient’s medications are actively reviewed and adjusted throughout episodes of acute care) has been included as a Joint Commission National Patient Safety Goal since 2005. Studies show mismanagement of medications can lead to poor outcomes for patients and helping patients manage their medications can prevent the chance of harm.

• A personal health record is one way to maintain a list of current medications.
• Help your patients create and maintain a medication list by accessing literature and tools.
  
  

Teach-back Method

Teach-back is a simple communication tool. After a provider shares new information with the patient and family, the patient is asked to teach-back the information. This allows the provider to correct misunderstandings and provide additional information if necessary. The provider can also assess the patient’s ability and confidence to manage their own care.

• Request a learning session on teach-back by Qualis Health staff.