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Kym Guy
Kym Guy

BrightStar offers private duty home care programs like HANDS and Clinical Pathways to reduce hospital readmissions and improve quality of life. HANDS provides home care after discharge to address issues that arise. Clinical Pathways is a condition-specific, transitional care program focused on reducing negative outcomes and optimizing quality of life through RN visits, education, and monitoring. These programs aim to address the top reasons for readmissions like medication management and lack of home support. They utilize technology, evidence-based practices, and specially trained staff to benefit patients, healthcare systems, and providers through better outcomes and efficiencies.

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The Role of Private Duty Home Care in Reducing Hospital Readmissions & Enhancing Quality Of Life Taking Private Duty Home Care to a Whole New Level Hospital Assisted Nurse Discharge Service (HANDS) and BrightStar Clinical Pathways
The Opportunity Hospital/Health System As part of the Patient Protection & Affordable data will be scrutinized at a Care Act (PPACA), there number of levels and are a number of changes failure to achieve certain that will impact reimbursement to national CMS benchmarks hospitals and other will result in healthcare systems Financial Penalties Excessive Readmissions National efforts are underway to reduce Less Robust Rewards potentially preventable Poor Customer Satisfaction hospital readmissions and optimize the patient Poor Outcomes of Care experience
*Centers for Medicare & Medicaid Services, Public Affairs, April 2009 Medicare data shows that nearly 1 in 5 patients who leave the hospital are readmitted within the next month and that more than 75% of these Healthcare readmissions are preventable* systems need to look for new solutions since Research has demonstrated that many existing of the return trips can be prevented approaches are with an in-home care program not solving the that includes proper education and problem. supervision.
Top Reasons for 30-day hospital readmissions: Failure to make follow-up appointments Lack of communication Failure to understand medication management Absence of in-home support Non-adherence to lifestyle recommendations Failure to understand and actively participate in the management of their chronic disease
At BrightStar we utilize a Best Practice approach to care following the National Quality Standards of The Joint Commission
Cutting Edge Clinical Programs The Framework: Making More Possible BrightStar We are companions on LifeCare the healthcare journey BrightStar our clients take. KidCare Clinical Pathways Staffing BrightStars clinical programs allow us to HANDS partner with the client, their family and their Person-Centered Care healthcare team to Clinical Expertise enhance quality of life National Quality Standards and improve care outcomes.
BrightStars Clinical Pathways and HANDS Program was inspired by nationally recognized care transition programs: Coleman Care Transition Intervention Program which reduced hospital readmissions by 50% at 30, 60 and 90 days
HANDS is a transitional care program focused on a safe transition home After leaving the hospital it is important that the patient have a direct link to an accessible care provider. HANDS provides that link, bridging the transition to home and addressing issues and questions that arise. Medicare agencies may not be able to be there within the 1st - 24 hours and sometimes not for 2-4 days.
BrightStars Hospital Accelerated Nurse Discharge Service (HANDS) is a transitional care program to facilitate a safe discharge home. It is ideally the beginning of a journey we take with the client and their healthcare team. HANDS: It begins at time of discharge and continues for a minimum of 24 hours critical transition time for What is it to re-engagement in the home setting. A visit by our Registered Nurse Care Our Manager is the cornerstone of the program Assessment, Medication Reconciliation, Disease Partners? State Education w/attention to Red Flag Symptoms Person-centered services performed by our CNA Transportation from hospital to home, Home Safety Check, Light Housekeeping, Retrieval of Simple Supplies (medications, groceries, etc), Light Meal Prep, Transition Check List which includes phone calls to loved ones, arranging/confirming follow-up appointment with discharging physician
Bcp inservice outreach linked in
HANDS Basic 3 hours CNA time HANDS Basic 1 RN Home Visit w/i 4-8 hours of Services hospital discharge HANDS Plus Everything included above Pre-discharge RN Visit at hospital (meet & greet, chart review, discharge instructions, etc) 1 additional RN visit 24/7 RN phone call availability for HANDS Plus 30 days Services Detailed medication instruction/med set-up if indicated
BrightStar Clinical Pathways Empowering individuals with chronic illness through our best practice approach
Simply put BrightStar Clinical Pathways is a patient centered condition-specific transitional care program Focused on reducing negative outcomes optimizing quality of life
BrightStar Clinical Pathways SM Patient Centered Evidence-based Condition-specific Best practice approach Time-limited (4 wks) RN Clinical Pathway Coordinator Specially Trained CNAs
BrightStar Clinical Pathways SM Heart failure COPD Pneumonia Acute MI Delirium & Dementia Diabetes Falls with Fracture
BrightStar Clinical Pathways Materials
BrightStar Clinical Pathways : Essentials Package 4 RN CPC Visits, 8 RN CPC Virtual Visits, 13 Specialty CNA Visits Week 1 Week 2 Week 3 Week 4 TTL RN Visit X X X X 4 RN Phone Call X X X X X X X X 8 CNA/HHA Visit X X X X X X X X X X X X X 13 25 Each face to face visit is a 2 hour condition-specific person- centered interaction focused on empowering the client as well as symptom surveillance
BrightStar Clinical Pathways MS DRGs and Frailty Factors MS DRG MCC *Frailty Factors Mult Diagnoses Essentials Mult. Medications MS DRG CC Plus ADL/IADL Deficits Unintentional Wt Loss Limited Support MS DRG Essentials Frailty Factors*
BrightStar Clinical Pathways : Essentials Plus Package 5 RN CPC Visits, 13 RN CPC Virtual Visits, 17 Specialty CNA Visits Week 1 Week 2 Week 3 Week 4 TTL RN Visit X X X X X 5 RN Phone Call X X X X X X X X X X X X X 13 CNA/HHA Visit X X X X X X X X X X X X X X X X X 17 35 Each face to face visit is a 2 hour condition-specific person- centered interaction focused on empowering the client as well as symptom surveillance
Other Essential Elements of BrightStar Clinical Pathways Care Together Web based communication and calendar tool for the client and their formal and informal care team; also promotes the self- management of chronic illness Building a PressGaney/Patient Impact National Patient Satisfaction Survey Platform of comparable to what many hospitals utilize Clinical We hold ourselves to a high service standard Excellence 9 out of 10 clients would refer us to a friend ABS 2.0 Data tracking of diagnosis, recent hospitalizations, reasons for admission/readmission; Staff assignment
Three key ways CareTogether enhances BCPs for clients & their families: 1. Condition specific educational materials, care Families using with physicians and case tools, resources managers can enhance communication and understanding and adherence!
Three key ways CareTogether enhances BCPs for clients & their families: 3. Keeping the family involved and updated is key part of 2. Calendar linked with ABS family and friends supporting shows client + Care Team visit the care and better choices of dates, times, name and more the Pathways program
HCAHPS vs BrightStar Press Ganey Survey http://hcahpsonline.org/Files/HCAHPS%20V6%200%20Appendix%20A%20- %20HCAHPS%20Mail%20Survey%20Materials%20(English)%202-16-2011.pdf Discharge Plan? Which questions match between HCAHPS & Press Ganey? Which questions illustrate opportunities for BrightStar to help?
BrightStar Clinical Pathways Foundational Concepts Person Centered The individual is more than the sum of their parts (or their diseases and medications) Patient Empowerment with Self Management of Chronic Disease BrightStar Clinical Pathway Team Leader Together Everyone Achieves More
Key BrightStar Clinical Pathways Coordinator Goals Motivate Clients To become as independent as possible in monitoring and maintaining their own health status Provide Clients with the knowledge and skills To make informed decisions about their healthcare and quality of life Reduce negative outcomes Hospitalizations, Readmissions, Urgent Care Visits ,ER Visits, Falls, Med Errors, etc Maintain active communication BrightStar Clinical Pathway Team, Clients Family and Physician, Other Healthcare Providers
HF Visit Details: RN & CNA
HF Knowledge Guidebook
HF Red Flag Alert
HF Symptom Tracker
Benefit to Patient: Continuous care for better outcomes RN education Earlier Discharge Reduce risk of falls relationship One on one help and Additional resources Improved medication guidance in the home to provide care, management from specially transportation, RX trained CNAs pick up, cleaning, etc Stay out the of hospital and the ER
What this program will mean to Healthcare Systems & Providers: Better Patient Outcomes Improve Efficiencies Improved Identify high-risk patients Communication Complements patient and and target specific family preparation for Improve flow of information interventions to mitigate discharge. Ensure a timely, between hospital, their risks for adverse efficient and safe 0utpatient physicians and events. With timely post discharge and transition provider. discharge in-home care to home. management and follow up. Better Image Improve patient and public Reduce likelihood of perception of care and result in higher satisfaction scores. potentially Promote customer loyalty & confidence in St. Mary's and preventable and enhance patient overall costly readmissions experience.
Why BrightStar? Our Difference: Joint Commission Accreditation Commitment to RN oversight Fully Licensed by the Person centered approach Press Ganey satisfaction survey CareTogether速 Licensed and insured for transport Flexible & responsive RN DON trains & competency tests Highly qualified and specially trained staff all CNAs Stringent screening and employment All patients receive in-home risk practices assessment to help reduce falls HANDS Continuity of care and care collaboration BrightStar Clinical Pathways Ongoing services to maintain safety Locally owned & operated and success
Ask Me How We Can Make More Possible For You! Kym.Guy@BrightStarCare.com 805.358.6022

More Related Content

Bcp inservice outreach linked in

  • 1. The Role of Private Duty Home Care in Reducing Hospital Readmissions & Enhancing Quality Of Life Taking Private Duty Home Care to a Whole New Level Hospital Assisted Nurse Discharge Service (HANDS) and BrightStar Clinical Pathways
  • 2. The Opportunity Hospital/Health System As part of the Patient Protection & Affordable data will be scrutinized at a Care Act (PPACA), there number of levels and are a number of changes failure to achieve certain that will impact reimbursement to national CMS benchmarks hospitals and other will result in healthcare systems Financial Penalties Excessive Readmissions National efforts are underway to reduce Less Robust Rewards potentially preventable Poor Customer Satisfaction hospital readmissions and optimize the patient Poor Outcomes of Care experience
  • 3. *Centers for Medicare & Medicaid Services, Public Affairs, April 2009 Medicare data shows that nearly 1 in 5 patients who leave the hospital are readmitted within the next month and that more than 75% of these Healthcare readmissions are preventable* systems need to look for new solutions since Research has demonstrated that many existing of the return trips can be prevented approaches are with an in-home care program not solving the that includes proper education and problem. supervision.
  • 4. Top Reasons for 30-day hospital readmissions: Failure to make follow-up appointments Lack of communication Failure to understand medication management Absence of in-home support Non-adherence to lifestyle recommendations Failure to understand and actively participate in the management of their chronic disease
  • 5. At BrightStar we utilize a Best Practice approach to care following the National Quality Standards of The Joint Commission
  • 6. Cutting Edge Clinical Programs The Framework: Making More Possible BrightStar We are companions on LifeCare the healthcare journey BrightStar our clients take. KidCare Clinical Pathways Staffing BrightStars clinical programs allow us to HANDS partner with the client, their family and their Person-Centered Care healthcare team to Clinical Expertise enhance quality of life National Quality Standards and improve care outcomes.
  • 7. BrightStars Clinical Pathways and HANDS Program was inspired by nationally recognized care transition programs: Coleman Care Transition Intervention Program which reduced hospital readmissions by 50% at 30, 60 and 90 days
  • 8. HANDS is a transitional care program focused on a safe transition home After leaving the hospital it is important that the patient have a direct link to an accessible care provider. HANDS provides that link, bridging the transition to home and addressing issues and questions that arise. Medicare agencies may not be able to be there within the 1st - 24 hours and sometimes not for 2-4 days.
  • 9. BrightStars Hospital Accelerated Nurse Discharge Service (HANDS) is a transitional care program to facilitate a safe discharge home. It is ideally the beginning of a journey we take with the client and their healthcare team. HANDS: It begins at time of discharge and continues for a minimum of 24 hours critical transition time for What is it to re-engagement in the home setting. A visit by our Registered Nurse Care Our Manager is the cornerstone of the program Assessment, Medication Reconciliation, Disease Partners? State Education w/attention to Red Flag Symptoms Person-centered services performed by our CNA Transportation from hospital to home, Home Safety Check, Light Housekeeping, Retrieval of Simple Supplies (medications, groceries, etc), Light Meal Prep, Transition Check List which includes phone calls to loved ones, arranging/confirming follow-up appointment with discharging physician
  • 11. HANDS Basic 3 hours CNA time HANDS Basic 1 RN Home Visit w/i 4-8 hours of Services hospital discharge HANDS Plus Everything included above Pre-discharge RN Visit at hospital (meet & greet, chart review, discharge instructions, etc) 1 additional RN visit 24/7 RN phone call availability for HANDS Plus 30 days Services Detailed medication instruction/med set-up if indicated
  • 12. BrightStar Clinical Pathways Empowering individuals with chronic illness through our best practice approach
  • 13. Simply put BrightStar Clinical Pathways is a patient centered condition-specific transitional care program Focused on reducing negative outcomes optimizing quality of life
  • 14. BrightStar Clinical Pathways SM Patient Centered Evidence-based Condition-specific Best practice approach Time-limited (4 wks) RN Clinical Pathway Coordinator Specially Trained CNAs
  • 15. BrightStar Clinical Pathways SM Heart failure COPD Pneumonia Acute MI Delirium & Dementia Diabetes Falls with Fracture
  • 17. BrightStar Clinical Pathways : Essentials Package 4 RN CPC Visits, 8 RN CPC Virtual Visits, 13 Specialty CNA Visits Week 1 Week 2 Week 3 Week 4 TTL RN Visit X X X X 4 RN Phone Call X X X X X X X X 8 CNA/HHA Visit X X X X X X X X X X X X X 13 25 Each face to face visit is a 2 hour condition-specific person- centered interaction focused on empowering the client as well as symptom surveillance
  • 18. BrightStar Clinical Pathways MS DRGs and Frailty Factors MS DRG MCC *Frailty Factors Mult Diagnoses Essentials Mult. Medications MS DRG CC Plus ADL/IADL Deficits Unintentional Wt Loss Limited Support MS DRG Essentials Frailty Factors*
  • 19. BrightStar Clinical Pathways : Essentials Plus Package 5 RN CPC Visits, 13 RN CPC Virtual Visits, 17 Specialty CNA Visits Week 1 Week 2 Week 3 Week 4 TTL RN Visit X X X X X 5 RN Phone Call X X X X X X X X X X X X X 13 CNA/HHA Visit X X X X X X X X X X X X X X X X X 17 35 Each face to face visit is a 2 hour condition-specific person- centered interaction focused on empowering the client as well as symptom surveillance
  • 20. Other Essential Elements of BrightStar Clinical Pathways Care Together Web based communication and calendar tool for the client and their formal and informal care team; also promotes the self- management of chronic illness Building a PressGaney/Patient Impact National Patient Satisfaction Survey Platform of comparable to what many hospitals utilize Clinical We hold ourselves to a high service standard Excellence 9 out of 10 clients would refer us to a friend ABS 2.0 Data tracking of diagnosis, recent hospitalizations, reasons for admission/readmission; Staff assignment
  • 21. Three key ways CareTogether enhances BCPs for clients & their families: 1. Condition specific educational materials, care Families using with physicians and case tools, resources managers can enhance communication and understanding and adherence!
  • 22. Three key ways CareTogether enhances BCPs for clients & their families: 3. Keeping the family involved and updated is key part of 2. Calendar linked with ABS family and friends supporting shows client + Care Team visit the care and better choices of dates, times, name and more the Pathways program
  • 23. HCAHPS vs BrightStar Press Ganey Survey http://hcahpsonline.org/Files/HCAHPS%20V6%200%20Appendix%20A%20- %20HCAHPS%20Mail%20Survey%20Materials%20(English)%202-16-2011.pdf Discharge Plan? Which questions match between HCAHPS & Press Ganey? Which questions illustrate opportunities for BrightStar to help?
  • 24. BrightStar Clinical Pathways Foundational Concepts Person Centered The individual is more than the sum of their parts (or their diseases and medications) Patient Empowerment with Self Management of Chronic Disease BrightStar Clinical Pathway Team Leader Together Everyone Achieves More
  • 25. Key BrightStar Clinical Pathways Coordinator Goals Motivate Clients To become as independent as possible in monitoring and maintaining their own health status Provide Clients with the knowledge and skills To make informed decisions about their healthcare and quality of life Reduce negative outcomes Hospitalizations, Readmissions, Urgent Care Visits ,ER Visits, Falls, Med Errors, etc Maintain active communication BrightStar Clinical Pathway Team, Clients Family and Physician, Other Healthcare Providers
  • 26. HF Visit Details: RN & CNA
  • 28. HF Red Flag Alert
  • 30. Benefit to Patient: Continuous care for better outcomes RN education Earlier Discharge Reduce risk of falls relationship One on one help and Additional resources Improved medication guidance in the home to provide care, management from specially transportation, RX trained CNAs pick up, cleaning, etc Stay out the of hospital and the ER
  • 31. What this program will mean to Healthcare Systems & Providers: Better Patient Outcomes Improve Efficiencies Improved Identify high-risk patients Communication Complements patient and and target specific family preparation for Improve flow of information interventions to mitigate discharge. Ensure a timely, between hospital, their risks for adverse efficient and safe 0utpatient physicians and events. With timely post discharge and transition provider. discharge in-home care to home. management and follow up. Better Image Improve patient and public Reduce likelihood of perception of care and result in higher satisfaction scores. potentially Promote customer loyalty & confidence in St. Mary's and preventable and enhance patient overall costly readmissions experience.
  • 32. Why BrightStar? Our Difference: Joint Commission Accreditation Commitment to RN oversight Fully Licensed by the Person centered approach Press Ganey satisfaction survey CareTogether速 Licensed and insured for transport Flexible & responsive RN DON trains & competency tests Highly qualified and specially trained staff all CNAs Stringent screening and employment All patients receive in-home risk practices assessment to help reduce falls HANDS Continuity of care and care collaboration BrightStar Clinical Pathways Ongoing services to maintain safety Locally owned & operated and success
  • 33. Ask Me How We Can Make More Possible For You! Kym.Guy@BrightStarCare.com 805.358.6022

Editor's Notes

  • #2: .
  • #3: President Obama proposed $320 billion in reductions to Medicare and Medicaid as part of his $3.8 trillion fiscal year 2013 federal budget proposal. The presidents plan, which is similar to a proposal the White House released in September, calls for cutting Medicare by $268 billion and Medicaid by $52 billion over 10 years.
  • #9: With the HANDS program BrightStar caregivers would provide timely assistance upon hospital discharge, maybe even transporting the patient to their place of residenceSo we will facilitate a safe and supportive environment before a Medicare home health agency has the ability to take over care management, We will serve as an additional link in care coordination. When MC agency and therapy com in collaborate with them supporting and reinforcing their teaching with the pt. - providing feedback , additional information they otherwise may not be able to obtain.- promoting even better outcomes than could have been possible before
  • #14: ANDREW
  • #15: it begins at the time of discharge and continues for a minimum of 4-weeks critical transition time for re-engagement in the home setting- matches the 30 readmission window associated with penalties
  • #19: SHARON
  • #22: Example, Daily Weight Calendar
  • #23: [explain Blue shows what Family schedules around the GREEN events that are those where BrightStar will be in the home]
  • #27: DOUG
  • #28: SHARON
  • #29: SHARON
  • #30: ANDREW
  • #31: Family related/situation related/ afternoon evening dischargetimely visit by our RNCP Coord. Is the cornerstone of the program with safety assessment, med reconciliation, disease state education with attention to red flag symptoms.Person-centered services performed by our CNATransportation from hospital to home, Home Safety Check, Light Housekeeping, Retrieval of Simple Supplies (medications, groceries, etc), Light Meal Prep, following our Transition Check List which includes phone calls to loved ones, arranging/confirming follow-up appointment with discharging physician and so on . Condition home may have been left inOut of the hospital -Until those unavoidable exacerbation of their chronic disease occurs
  • #33: Our joint commission is firm evidence about the client care we provide. Both our accreditation and client satisfaction scores . At BS we have a wonderful asset in our PG reporting. We have an exclusive relationship with PG. our questions map those of HCAHPS and HHCAPSYou have a great deal of focus on client satisfaction and so do weSt BS we understand the importance of patient satisfaction-Our last PG survey revealed that 98% of our customers would refer us to family or friend.CareTogether. we know you have a similar program in Caring Bridge - Care Together is different and complementary. -The calendar/visit function and condition specific pt education materials that weve added to CareTogether really make it unique.