Saralin Tiedeman

Post-Acute Care Team Update

By Saralin Tiedeman, MS, OTR/L, Post-Acute Project Manager

Millennium’s network of Post-Acute Providers, comprised of 50 Skilled Nursing Facilities (SNF’s) and six Certified Home Healthcare Agencies (CHHA), have been hard at work to meet the milestones of their respective projects.

INTERACT Program
For the SNF’s, Project 2bvii: Implementing the INTERACT program contained 10 milestones focused around the adoption and implementation of the Interventions to Reduce Acute Care Transfers project, INTERACT.

Each facility had to:

  • identify an INTERACT Champion
  • adopt evidence based care protocols and tools
  • roll-out an extensive training program to staff
  • incorporate hospitalization review and tracking into their on-going Quality Assurance &. Performance Improvement (QAPI) initiatives
  • enhance their patient and family educational materials

In many instances, the implementation of this program coincided with the transition from paper-based medical records to an electronic medical record system. The personal effort of all staff involved cannot be minimized, both undertakings were enormous projects…doing them simultaneously only magnified the effort, time, and resources required! Because of the hard work of our SNF providers we have met 9/10 State milestones for Project 2bvii, therefore securing 90% of the funding allotted to this specific project.

Hospital Home Care Collaborative Solutions
For Project 2bviii: Hospital Home Care Collaborative Solutions, our Certified Home Healthcare Agencies (CHHA) had to adopt similar “INTERACT-like” evidence-based care protocols and tools; perform hospitalization tracking and root cause analysis; train staff on new communication forms and techniques; and roll-out use of enhanced patient and family education materials.

In addition, the development of the Rapid Response Team care model through the Visiting Nurses Association has been used to divert appropriate patients arriving in Emergency Departments to the community using home care services. This process ensures patients have the community support required to avoid an unnecessary hospitalization and that they are receiving the right care at the right place at the right time.

Due to the hard work and effort of our CHHA providers, Millennium achieved 12/12 milestones and received 100 percent of the funding associated with this project.

Millennium would like to thank our entire network of Post-Acute Care Providers. This group of providers had aggressive timelines to complete all 22 assigned milestones by 9/30/2016. We appreciate all the time and effort given to achieving these goals!

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