For Professionals
The Kenosha County Care Transitions Coalition has implemented evidence based and local pilot interventions to address hospital readmissions and improved transitions of care across settings. Our overview document provides a historical perspective of these efforts. Below you will find more information about the current interventions, local resource people and areas of ongoing interest. For general information about the Coalition, please contact Helen Sampson at the Kenosha County Aging and Disability Resource Center,Helen.sampson@kenoshacounty.org
Kenosha shares their work at the MetaStar Community Outcomes Summit 2019
along with other Coalitions across the state. From left Marie Seger (Sheboygan County), Dominic Wondolkowski (Jefferson County), Jennifer Fischer (Dane County), Paula Hinrichs (Chippewa Valley)
Kenosha County on far right: Amy Mlot (Society's Assets), Helen Sampson (ADRC), Rita Hagen (Hospice Alliance)
Dani Kroll (PACT), Jodi Sadlon (Mid-level Provider), Barb Beardsley (INTERACT) and Helen Sampson
share the story of the Kenosha County Care Transitions work at the Wisconsin Focus Conference 2015
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Interventions
INTERACT (Interventions to Reduce Acute Care Transfers) is a quality improvement program that focuses on the management of acute change in resident condition. It includes clinical and educational tools and strategies for use in every day practice in long-term care facilities.
INTERACT Tool for Assisted Living
Local contact person: Barb Beardsley, Director of Nurses, Brookside Care Center, Barbara.Beardsley@kenoshacounty.org
PACT (Patient Adherence and Competency of Therapy) offers has three main features - Patient-friendly packaging that helps individuals organize medication and remember to take them; therapy management with monthly profile reviews to ensure we package and send out the appropriate medications each month; and free home delivery. Good Value Pharmacy.
Local contact person: Andrea Wood, andrea@goodvaluerx.com
PREPARING TO GO HOME - Social workers at United Hospital System complete the “Preparing to Go Home” document with the CHF patients who are going home with no services. The social workers then provide a follow up phone call within 72 hours to review the document and identify any post discharge needs.
Local contact person: Jaymie Laurent, Director, Social Services and Spiritual Care, United Hospital System, Jaymie.Laurent@uhsi.org
PHYSICIAN FOLLOW UP APPOINTMENT - Prior to hospital discharge, physician follow up appointments are scheduled within 7 days for patients with Congestive Heart Failure regardless of discharge setting (i.e. home: self care, home: home health care, or nursing home).
Local contact person: Jaymie Laurent, Director, Social Services and Spiritual Care, Froedtert South, Jaymie.Laurent@froedtertsouth.com
Follow Up Questions - To integrate best practice related to physician follow up and medication management with community based data collection, ADRC, Right At Home, Kenosha Visiting Nurse Service and Society’s Assets are all asking the same follow up questions when interacting with a recently discharged patient (see form below). Community providers offer linkages, support and teaching as appropriate for their scope of practice. Data collection is then shared with our hospital partners.
SUSTAINING A SUCCESSFUL INTERVENTION - Using a PDSA (Plan, Do, Study, Act) model, once data has been collected and impact demonstrated, the next step is to insure ongoing viability. How will the change be sustained? What will be sustained (all or part of the intervention) and what is the goal? How will we know it continues to be successful?
Areas of Interest
Falls Prevention: In Wisconsin, falls have surpassed motor vehicle crashes as the most common cause of injury related death. A large majority of fall-related deaths (87%) and inpatient hospitalizations (70%) involve people age 65 or older and hospitalizations and emergency department visits due to falls result in $800 million in hospital charges each year in Wisconsin.
Health Literacy: The degree to which individuals have the capacity to obtain, process, and understand basic information and services needed to make appropriate decisions regarding their health.
Motivational Interviewing: Motivational interviewing (MI) supports health behavior change by helping individuals explore and resolve their ambivalence about change without evoking resistance. MI techniques can be incorporated into routine patient care.
Health Team Works has several helpful resources to support the use of Motivational Interviewing in primary care including the video Motivational Interviewing: Evoking Commitment to Change