Need Help?

Email:
 
Call:
617-301-4800
866-787-0831
(Toll Free)
 
Available
Monday-Friday
9am-5pm ET

Session Agenda

Wednesday, April 23, 2014
 
​7:00 AM - 8:00 AM Registration and Continental Breakfast​
​8:00 AM - 8:20 AM Welcome, Introductions, and Overview
Emalie Parkhurst
This session will introduce IHI, the faculty, and the agenda for the two-day seminar.
​8:20 AM -9:20 AM

Overview of IHI’s Approach to Reducing Avoidable Rehospitalizations
Gail Nielsen
This session will make the case for creating a more patient-centered ideal transition home. The case for improvement, elements of the STAAR initiative and strategies to get results will be presented. Participants will be able to:

  • Identify promising interventions to reduce avoidable readmissions
  • Describe IHI’s approach to improving care transitions and reducing avoidable readmissions
​9:20 AM -
10:20 AM

Identifying Opportunities for Improvement and Developing Aim Statements
Peg Bradke
This session will review the strategies for identifying opportunities for improvement through the use of data and through the eyes of patients and family caregivers. A discussion of the recommended infrastructure for improving care transitions will include the roles of the executive sponsor and cross-continuum teams. Key design elements will be discussed. Participants will be able to:

  • Describe the role of the executive sponsor
  • Identify strategies to establish cross continuum team collaboration
  • Describe methodologies for identifying opportunities for improvement from the diagnostic review
  • Develop an aim statement to provide a focus improvement initiatives
10:20 AM -10:40 AM Break
​10:40 AM -11:30 AM

Enhanced Assessment for Post-Hospital Needs
Maureen Carroll
This session will provide strategies and interventions to answer the question: How can we gain a deeper understanding of the comprehensive post-discharge needs of the patient through an ongoing dialogue with the patient, family caregivers and community providers? Participants will be able to:

  • Identify failures in current processes to assess post-discharge needs from the literature and their own experiences
  • Identify key improvements to enhance the assessment of a patient’s post-discharge needs
  • Discuss strategies for getting started and collaborating with family caregivers and community-based partners
11:30 AM -12:15 PM

Effective Teaching and Enhanced Learning
Eric Coleman and Gail Nielsen
This session will provide strategies and interventions
to answer the question: How can we gain a deeper understanding of patient and family caregiver understanding and comprehension of the clinical condition and self-care needs after discharge? Participants will be able to:

  • Identify failures in current processes for teaching patients
  • Utilize health literacy principles and techniques to improve patient and family understanding of their clinical conditions and care plans
  • Demonstrate the use of Teach Back
12:15 PM -1:00 PM Lunch
1:00 PM -1:40 PM Effective Teaching and Enhanced Learning (continued)
Eric Coleman and Gail Nielsen
​1:40 PM -2:40 PM

Developing Post-Hospital Follow-Up Care Plans
Maureen Carroll
This session will provide strategies and interventions to answer the question: How can we develop a post-acute care plan based on the assessed needs and capabilities of the patient and family caregivers? Participants will be able to:

  • Identify failures in current processes to arrange post-discharge care from the literature and their own experiences
  • Describe opportunities for identifying patients who are at moderate- and high-risk for readmission
  • Identify useful tips and processes for reliable and effective follow-up to keep patients safe after acute care
2:40 PM -3:00 PM ​Break
​3:00 PM -
4:00 PM

Real-Time Handover Communication
Peg Bradke and Eric Coleman
This session will provide strategies and interventions to answer the question: How can we effectively communicate post-acute care plans to patients and community-based providers of care? Participants will be able to:

  • Identify failures in current processes to provide handover information from the literature and their own experiences
  • Describe handover improvements and useful ways to get started
  • List tips and techniques for partnering across the continuum of care to get results
​4:00 PM -
5:00 PM
Case Studies (UCSF Heart Failure Program and St. Luke’s Hospital)
Peg Bradke and Maureen Carroll
Day 1 Feedback
​5:00 PM -
6:00 PM
Networking Reception
 
 
Thursday, April 24, 2014
 
​7:00 AM -8:00 AM Continental Breakfast
8:00 AM -8:15 AM Demonstration of www.ihi.org
Emalie Parkhurst
​8:15 AM -8:30 AM ​Debrief from Day 1 and Introduction to Day 2
Gail Nielsen and Eric Coleman
​8:30 AM -10:00 AM

Engaging Patients and Families in Improving Care Transitions
Eric Coleman and Gail Nielsen
Faculty will share, from their experience, the benefits of involving patients and families as partners in redesigning discharge processes. Participants will share how they have involved patients and families in improvement and redesign of care processes. Participants will be able to:

  • Describe the benefits of involving patients and families as partners
  • Recognize the valuable role of family caregivers in high quality care transitions
  • Share tips on getting patients and family members involved and removing barriers to effective partnerships
  • Use a self-assessment tool on readiness for patient engagement
10:00 AM -10:20A M Break
10:20 AM -11:00 AM

Improving Transitions into Skilled Nursing Facilities
Peg Bradke
This session will provide information about key changes that clinicians and staff in hospitals and skilled nursing facilities can implement to improve the timely and reliable continuity of care for residents who reside in community settings of care. Participants will be able to:

  • Identify effective tools from the INTERACT Version 3.0 Program that are designed to prevent acute care transfers from SNFs to acute care hospitals
  • Discuss specific strategies for enhancing care coordination between hospitals and skilled nursing facilities
11:00 AM -
12:30 PM

​Improving Transitions to Home and Community-based Care
Eric Coleman
This session will describe two evidence-based models of care, the Care Transitions Intervention (CTI) and the Transitional Care Model (TCM), to support and provide coaching to patients after being discharged from an acute care hospital. Participants will engage in discussion of successful models for palliative care, comprehensive community-based services for the elderly and intensive care management programs. Participants will be able to:

  • Describe elements of evidence-based transitional care models
  • Describe various models for providing intensive care management for high-risk patients
  • Identify successful models for advanced illness planning
​12:30 PM -1:15 PM ​Lunch
​1:15 PM -2:15 PM

Using Measurement for Learning and Strategies to Achieve Results
Gail Nielsen
This session will provide guidance for participants to develop improvement plans for testing, implementing and spreading changes to reduce avoidable readmissions. Faculty will share strategies to engage senior executive support and help front-line teams in care settings across the continuum to achieve better levels of performance. Participants will be able to:

  • Explain the recommended measurement strategy and rationale for using outcome and process measures to guide learning and assess progress
  • Describe strategies for getting results in overburdened care delivery systems
  • Apply strategies and tools for creating an action plan to coordinate and leverage all initiatives to improve care transitions
​2:15 PM -2:30 PM Wrap-up and Adjourn