Tip:
Highlight text to annotate it
X
Rhode Island’s Washington County Transitions Coalition Video Transcript
(Start of Video) Graphic:
WASHINGTON COUNTY TRANSITIONS COALITION. RHODE ISLAND.
Jennifer W. Fairbank, RN, BSN, CNHA Executive Director, South County Nursing and
Rehabilitation Center Co-Chair Washington County Transitions Coalition:
“The Initial catalyst for the Washington County Coalition was Dr. Bandola, who is a
provider in the community, called a number of different providers to kind of vent and
talk about issue that we were having with the hospital. The light bulb went on about
three quarters of the way through this meeting and we all kind of looked around at each other
and said,” wow, we can get some things accomplished here!”
Lynne Chase Senior Program Administrator, Healthcentric
Advisors Liaison, Washington County Transitions Coalition:
“Slowly but surely the word is getting out that you want to be part of the solution and
in order to do that, you need to join this group. You need to bring your voice to the
table, and more importantly, you need to take action; that’s why this group is so successful.”
Graphic: WHO IS INVOLVED IN THE COALITION?
OVER 15 PROVIDERS THROUGHOUT THE COUNTY: SKILLED NURSING FACILITIES
PATIENT-CENTERED MEDICAL HOMES PHYSICIAN CHAMPIONS
ASSISTED LIVING FACILITIES HOME HEALTH AGENCIES
PHARMACIES HOSPITALS
Graphic: (logo splash)
Graphic: COLLABORATING TO IMPROVE TRANSITIONS OF CARE
Graphic: QIO INVOLVEMENT
Jennifer W. Fairbank, RN, BSN, CNHA: “A couple meetings in is when Healthcentric
Advisors came in to the picture and we became aware of that QIO role and we were on board
with it right away.” Lynne Chase:
“We did come in to an existing coalition and we needed to figure out what we were going
to do to add value to a program that had great interventions in place but they weren’t
measuring them. So there were two things we said we were going to do: one is help them
measure and show their success and the other was highlight their success. And we’ve been
Graphic: 5 FACTORS LEADING TO COALITION SUCCESS
Graphic: 1. PROVIDER-DRIVEN
Lynne Chase: “The Washington County Coalition is provider-driven.
It’s run, it’s led, the actions are based on what the providers want to do, and that’s
going to create sustainability.” Lynne Driscoll, RN, CCM
Manager of Case Management, South County Hospital Co-Chair Washington County Transitions Coalition:
“It started with providers. It started with two providers coming together and pulling
in people that they knew could solve some of these problems.
Graphic: 2. INNOVATIVE THINKING
Jennifer W. Fairbank, RN, BSN, CNHA: “We think outside of the box. We encourage
everyone to come to the table with different ideas.”
Lynne Driscoll, RN, CCM: “When we got together we decided that a
shadowing program was the best way to do that.” Lynne Chase:
“So it’s ‘spend half a day in my shoes.’ And they go into the other facility and they
get to see what that other person does.” Karen Hockhousen, RN, BSN, ICCS
Director of Clinical Services, VNS Home Health Services
Co-Chair Washington County Transitions Coalition “And initially one of the outcomes of the
shadowing program was the institution of the Nurse-to-Nurse Report between hospital and
skilled nursing facility.” Lynne Driscoll, RN, CCM:
“We also utilize pharmacy students at URI. They’re working in the hospital, they’re
working in home care…so they’ve done a lot of really creative things.”
Lynne Chase: “Collaboration and communication are critical
to making a successful change to improving patient care.”
Graphic: 3. FOSTERING COLLABORATIVE SOLUTIONS
Jennifer W. Fairbank, RN, BSN, CNHA: “I think initially some people are reluctant
to come to the table because they have to air their dirty laundry.”
Lynne Driscoll, RN, CCM: “And it wasn’t about blaming, it was more
about identifying problems and coming up with solutions.”
Karen Hockhousen, RN, BSN, ICCS “We want to talk about issues and concerns;
we want to do that constructively.” Graphic:
4. PATIENT-CENTERED / PATIENT-DIRECTED Lynne Driscoll, RN, CCM:
“We are patient-centered. We are always looking to see how patients are reacting,
getting patients’ input and trying to provide the best quality of care for patients.”
Karen Hockhousen, RN, BSN, ICCS “At our coalition meetings we usually open
up the meeting with a patient story.” Coalition Member giving patient story in a
meeting: “He went from one setting – the hospital
– after a fall, to another setting. He got what he needed there, was hooked up with the
right information, and is now going home to the home setting, which is what he wanted.”
Lynne Chase: “Slowly but surely we’re moving from a
patient-centered where we’re thinking about the patient at every meeting, to a patient-directed
where we’re actually having the patient involved in the work, in the room and guiding
what we do next.” Graphic:
5. UNIQUE NEEDS / ALIGNED EFFORTS Jennifer W. Fairbank, RN, BSN, CNHA:
“As a coalition, it’s unique, but I don’t think so unique that it can’t be carried
across all lines of business.” Karen Hockhousen, RN, BSN, ICCS
“We did institute a liaison in the hospitals and several of the local skilled nursing facilities.
And it wasn’t a one-size-fits-all because each facility has their own goals for what
they see will be beneficial from that relationship.” Lynne Chase:
“We really are trying to align the efforts so that it’s a full community solution.”
Jennifer W. Fairbank, RN, BSN, CNHA: “A lot of people that have just an amazing
commitment to healthcare. Not just on a professional level, but there’s a personal passion and
you can see that personal passion in everyone that sits on that coalition and comes to our
meetings.” Lynne Driscoll, RN, CCM:
“We’re caring, we’re innovative, and we’re passionate about providing good, sustainable
healthcare for everybody.” Lynne Chase:
“Patients are benefiting because providers are talking.”
Jennifer W. Fairbank, RN, BSN, CNHA: “I think it’s more than sustainable. I
think it’s a model. I think anyone in healthcare would be crazy not to want to get involved.
It just doesn’t make any sense not to do this.”
Graphic: BE A PART OF THE SOLUTION
Closing Graphics: Created by CFMC, Colorado’s Quality Improvement
Organization (QIO) by the Integrating Care for Populations and
Communities National Coordinating Center (ICPC NCC)
A Special Thanks to: Washington County Transitions Coalition Members
Healthcentric Advisors (Rhode Island’s Quality Improvement Organization)
A Special Thanks to: Physician Champions:
• Jeffrey Bandola, MD • Timothy Drury, MD
• Louis Rubenstein, MD A Special Thanks to:
Washington County Transitions Coalition Co-Chairs: • Lynne Driscoll, RN, CMM – South County
Hospital • Jennifer Fairbank, RN, BSN, CNHA – South
County Nursing and Rehabilitation Center • Karen Hockhousen, RN, BSN, ICCS – VNS
Home Health Services Producer: Cyndi Ortiz
Creative Director: Kimothy Pikor Editor: AJ Koch
Designer/Animator: Dave Drage This material was prepared by CFMC, the Integrating
Care for Populations & Communities National Coordinating Center, under contract with the
Centers for Medicare and Medicaid Services (CMS), an agency of the U.S. Department of
Health and Human Services. The contents presented do not necessarily reflect CMS policy. PM-4010-262
CO 2013. (End of Video)