“One of the most impressionable times to work with a diabetes patient is immediately following discharge,” explains Shelley Kikuchi, the team’s management co-lead.

By reaching out to patients during those “moments that matter,” the team has increased the number of diabetes patients with blood sugar levels under control. Their practices have proven so effective they are now part of routine treatment for patients with diabetes regionwide.

“The close follow-up with patients helps us better manage their medication and support their healthy lifestyle choices,” says Alana Busekrus, RN, the team’s labor co-lead and a certified diabetes care and education specialist who is a member of the Hawaii Nurses and Healthcare Professionals (HNHP) union.

To help patients manage diabetes, the team monitors their blood sugar levels, orders lab tests, adjusts medications and offers advice on nutrition and exercise. These interventions are important because Native Hawaiians and Pacific Islanders are among those at higher risk of diabetes, a serious chronic disease.

Overcoming obstacles

But achieving success wasn’t easy.

Early efforts to provide post-discharge care proved labor intensive and fell short of regional goals for controlling patients’ blood sugar levels, recalls Anna Sliva, RN, a care manager with the team and an HNHP member.

Health outcomes improved after unit-based team members standardized the discharge process in 2019. Nurses collaborate with Transitional Care clinical pharmacists to identify high-risk diabetic patients before they leave the hospital. Care managers follow up by showing patients how to use glucose monitors to track their blood sugar levels.

Results were significant. Within 3 months after discharge, 30% of patients lowered A1c blood sugar levels by at least 0.5 percentage points. And within 6 months, 50% of patients lowered A1c levels by at least 1 percentage point.

“Thanks to our team’s excellent work,” says Kikuchi, “the ‘moments that matter’ discharge workflow has become a standard part of our practice, benefiting some of our most vulnerable diabetic patients.”

Communicator (reporters)

Jennifer Gladwell

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Sherry Crosby

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03/22/2021 - 12:00

Read more about Making Moments Matter

Questionnaire Shaves Wait Times for Gastrointestinal Patients

Creating a questionnaire and training staff on the new process
Partnering with the business office supervisor and asking the receptionists to hand the form to all GI procedure patients at check-in
Decreasing/minimizing the RN time to review the entire document in detail and focus on patients' specific questions
Giving patients a choice between RN discharge or MD discharge

What can your team do to improve efficiencies in your department? What else could your team do to help shorten patients' wait times?

Read more about Questionnaire Shaves Wait Times for Gastrointestinal Patients

Work With Patients to Ensure Follow-Up Appointments tyra.l.ferlatte Tue, 08/19/2014 - 16:19

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follow-up appointments

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Work With Patients to Ensure Follow-Up Appointments

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Unit assistants help avoid costly readmissions

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Simple Notebook Improves Care

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Kate Darby Rauch

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By taking the time to find out patient preferences, unit assistants help patients keep their critical post-discharge appointments—and help KP avoid tens of thousands of dollars in readmission costs

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Timely follow-up appointments can help prevent costly and stressful hospital readmissions.

But making these appointments can prove difficult during hectic hospital discharges, or after a patient has returned home.

Even when appointments are made, they aren’t always kept.

The Unit Assistants UBT at Redwood City Medical Center took on the challenge of increasing the number of follow-up appointments scheduled to occur within seven days after discharge.

Team members knew they could increase the likelihood of patients keeping these appointments by working with them and their family support members before they left the hospital.

“Obviously we can’t force a patient to go to an appointment, but we can try to make appointments when it’s suitable for them,” says union co-lead and senior unit assistant Judith Gonzales.

Starting with one hospital floor, unit assistants spoke with patients before they were discharged, taking notes on which days and times they preferred for appointments, and then passed the written information on to the staff members responsible for scheduling.

In eight weeks, the percentage of patients who kept their follow-up appointments jumped from 50 to 60 percent and soon the whole hospital was on board.

“We piloted in July 2013, and two months later we rolled it out to all the floors,” says management co-lead Amelia Chavez, director of operations, Patient Care Services. “Our percentages climbed and climbed. It was phenomenal.”

By January 2014, 86 percent of follow-up appointments at Redwood City were taking place in the seven-days, post-discharge window.

“The patients loved it; we included them in the process,” Gonzales says. “This improved our patient satisfaction scores as well.”

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Non-LMP

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Tyra Ferlatte

http://assets.lmpartnership.org/?r=31579

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