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Data-Driven Care Transition Management: Action Plans for High-Risk Patients

Data-Driven Care Transition Management: Action Plans for High-Risk Patients

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Providers who signed on for San Francisco Health Network's Care Transitions Task Force shared not only a professional passion for care transitions work but also the belief that care transitions responsibility should be spread across the healthcare continuum.

And once the SFHN task force mined a 'black box' of administrative data buried in more than 60 siloed databases across its health network, continuum-wide care transition improvement seemed attainable.

Data-Driven Care Transition Management: Action Plans for High-Risk Patients documents how SFHN's deep data dive triggered the development of a data dashboard, a hospital discharge database and a set of uniform standards and practices that have streamlined care transitions within its safety net population.

In this 25-page resource, Dr. Michelle Schneidermann, associate clinical professor of medicine for the division of hospital medicine at the University of California San Francisco/San Francisco General Hospital, describes how learnings gleaned from the data analysis on readmission rates, vulnerable populations, and pain points within SFHN sparked action plans, pilots and partnerships designed to standardize patient handoffs and post-discharge follow-up in a diverse patient population.

Dr. Schneidermann, who is also medical director of the San Francisco Department of Public Health Medical Respite and Sobering Center, offers the following insights in this report:

The task force's inventory and gap analysis of transitions, initiatives and programs across its health network;
Development of hospital-primary care partnerships to ease patients' discharge to home;
Clinic-based interventions of telephonic follow-up by a readmission prevention team for patients newly released from the hospital;
Development of a hospital discharge database to help outpatient clinics efficiently track and target their patients;
Division of the task force into three distinct groups and the care transitions standards work completed by each faction;
Defining the SFHN class of patients considered at high risk for readmission to the hospital;
Scaling of pilot post-discharge interventions across all clinics;
Development of templates to standardize post-discharge protocols;
Future enhancements to Task Force initiatives, including recruitment of patients to the task force and the impact of behavioral health diagnoses on hospital readmissions;

and much more.


SFHN's Standardized, Multidisciplinary Approach to Post-Acute Patient Hand-Offs
Origins of Care Transitions Task Force
Shifting Focus to Administrative Data
Hospital-Primary Care Partnerships
Pilot of Post-Discharge Outreach
Constructing a Discharge Database
Standardizing Approaches to Transitional Care
Interventions for High-Risk Patients
Pain Points and Next Steps
Q&A: Ask the Expert
Challenges from Behavioral Diagnoses
Communication Between Inpatient and Ambulatory Staff
Pre-Discharge Hospital Visits
Behavioral Health Presence on Multidisciplinary Team
Engaging Primary Care Providers and Staff
Routing of Post-Discharge Summaries
Attendance at 7-Day Follow-Up
Home Visit Specifications
Care Transition Tools and Workflow
Patient Engagement Strategies
Pharmacists’ Role in Care Transition Management
Ensuring a Standardized Approach
Follow-Up and Readmissions
Recruiting Patients for Care Transitions Task Force
Glossary
For More Information
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