Patient Engagement through Patient Centered Goals

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Patient Engagement Patient Engagement through Patient through Patient Centered Goals Centered Goals Chris Walker Chris Walker MSN, RN, MHA MSN, RN, MHA St. Cloud St. Cloud Hospital/CentraCare Hospital/CentraCare Health Health

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Patient Engagement through Patient Centered Goals. Chris Walker MSN, RN, MHA St. Cloud Hospital/CentraCare Health. Typical Transition Failures. Self-care Care Planning Health Literacy/Communication. Improvement Strategies. Self-care Care Planning - PowerPoint PPT Presentation

Transcript of Patient Engagement through Patient Centered Goals

Page 1: Patient Engagement through Patient Centered Goals

Patient Engagement Patient Engagement through Patient Centered through Patient Centered

Goals Goals Chris WalkerChris Walker

MSN, RN, MHAMSN, RN, MHA

St. Cloud Hospital/CentraCare HealthSt. Cloud Hospital/CentraCare Health

Page 2: Patient Engagement through Patient Centered Goals

Typical Transition FailuresTypical Transition Failures

Self-careSelf-care

Care PlanningCare Planning

Health Literacy/Communication Health Literacy/Communication

Page 3: Patient Engagement through Patient Centered Goals

Improvement StrategiesImprovement Strategies

Self-careSelf-care

Care PlanningCare Planning

Health Literacy/Patient-Provider Health Literacy/Patient-Provider CommunicationCommunication

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Illness Management & RecoveryIllness Management & Recovery(IM & R)(IM & R)

PsychoeducationPsychoeducation Behavioral tailoring for medication adherenceBehavioral tailoring for medication adherence Relapse prevention trainingRelapse prevention training Coping skills trainingCoping skills training Social skills training Social skills training

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Recovery GoalsRecovery Goals

Unique to each individualUnique to each individual

Must be personally meaningfulMust be personally meaningful

Vary from modest to ambitiousVary from modest to ambitious

Use of Motivational Interviewing (MI) Use of Motivational Interviewing (MI)

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Unique Treatment Plan (UTP) Unique Treatment Plan (UTP)

Criteria and types Criteria and types

Plan development with patient and Plan development with patient and interdisciplinary team interdisciplinary team

Electronic health record accessElectronic health record access

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Interdisciplinary Staffing NoteInterdisciplinary Staffing Note RN/SW CommunicationRN/SW Communication

Plan of care Plan of care Day of IP stayDay of IP stay PayorPayor UTP (yes/no)UTP (yes/no) Suicide risk assessmentSuicide risk assessment Violence risk Violence risk

assessmentassessment Event changesEvent changes Family meeting Family meeting

Illness, Management & Recovery (IM & R) Illness, Management & Recovery (IM & R) Recovery goalRecovery goal

Dialectical Behavior Therapy Protocol Dialectical Behavior Therapy Protocol Behavioral Chain Analysis Behavioral Chain Analysis Diary cardDiary card

Integrated Dual Disorder Treatment (IDDT)Integrated Dual Disorder Treatment (IDDT) Staged within 3 days of admissionStaged within 3 days of admission Stages of mental health and/or substance use Stages of mental health and/or substance use

Transition Plan Transition Plan Disposition needsDisposition needs Medical follow up Medical follow up

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Bedside Shift Report Bedside Shift Report

Warm handoffWarm handoff SBAR reportSBAR report Focused pt and safety assessmentFocused pt and safety assessment Review of tasksReview of tasks Identify patient and family needs/concernsIdentify patient and family needs/concerns

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My Care BoardMy Care Board

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Managing My Recovery Managing My Recovery

Relapse prevention planRelapse prevention plan Reasons for livingReasons for living Possible triggersPossible triggers Early warning signsEarly warning signs Support peopleSupport people Recovery goalRecovery goal Strategies for success Strategies for success

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Discharge Checklist Discharge Checklist

Specific to disciplinesSpecific to disciplines

Improved consistencyImproved consistency

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Transforming Care at the Transforming Care at the Bedside (TCAB) Bedside (TCAB)

Purpose Purpose

Rapid change cycle (PDSA)Rapid change cycle (PDSA)

Positive culture changePositive culture change

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References References www.rarereadmissions.org Nurse Bedside Shift Report. June 2013. Agency for Nurse Bedside Shift Report. June 2013. Agency for

Healthcare Research and Quality, Rockville, MD. Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/hospital/engagingfamilies/strategy3/index.html

Meyer, P. & Gingerich, S. (2009). Meyer, P. & Gingerich, S. (2009). Supporting Illness Supporting Illness Management Recovery on Inpatient Units. Management Recovery on Inpatient Units.

2007: Robert Wood Johnson Foundation & Institute 2007: Robert Wood Johnson Foundation & Institute for Healthcare Improvement. for Healthcare Improvement. TCAB Communications TCAB Communications GuidelinesGuidelines


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