Connecting the Dots: Multidisciplinary Care Planning in the Emergency Department

2.50
Hdl Handle:
http://hdl.handle.net/10755/198300
Title:
Connecting the Dots: Multidisciplinary Care Planning in the Emergency Department
Abstract:
[ENA Annual Conference 2011 - Evidence-based Practice Presentation] Connecting the Dots: Multidisciplinary Care Planning In the Emergency Department

Purpose: To improve patient safety, quality and continuity of care for ED patients seeking emergency care more than once per month. To improve care coordination that promotes utilization of more appropriate external resources and to reduce caregiver stress associated with the care of this population.

Design: Patient safety and staff satisfaction initiative

Setting: Urban teaching, 52,000 visits, non trauma hospital.

Participants: All patients seen in the ED more than once per month. The Multidisciplinary care planning team consists of the ED Clinical Manager, Physicians, Staff Nurses, Case Management, Social Services, Psychiatry, Risk Management, Inpatient Nursing, Hospitalist and Primary Physicians.

Methods: An electronic patient tracking system is used to collect data and systematically identify the high utilizer patient population. The data is analyzed and prioritized by the team to initiate a care plan intervention. This analysis lead to the realization that many patients in this group are complex and require individualized care. One size does not fit all. The number of patients identified thus far exceeds 200 patients. Once a patient has been selected, a care conference with the multidisciplinary team is organized. The case is presented and a discussion follows. Each discipline contributes a recommendation to building the individualized care plan such as: Psychiatry evaluations, behavior modifications, medication regimen changes, primary care establishment, appointments and home care services. Primary care physicians are involved in the process by attending the meeting or through telephone consultation with team members. The patient is also part of this process. Recommendations for care are discussed during admission or provided in a letter mailed to their home for outpatients. Care plan communication is also provided to primary physicians, hospital staff and stored in the medical record.

Results/Outcomes: Establishing a consistent, multidisciplinary model of practice will serve as a catalyst for a culture change in which clinicians assess, plan, intervene and collaborate with primary physicians to transition care to the community. Care planning is a resource intensive process requiring many partners to design and implement a therapeutic plan of care with appropriate resource management that includes strategies that staff can implement. This process guides the team to appropriate interventions and promotion of positive health outcomes that reduces the need for ED visits. Communication is improved between all stakeholders because there is a shared plan and common goal. The data shows that there has been reduced visit frequency for those that have formalized multidisciplinary care plans. Staff nurses were frustrated with the fragmented care and increased visits but now express that they are part of the solution, having direction with a plan in place.

Implications: Multidisciplinary care planning is resource intensive but provides the much needed missing link in healthcare. Historically the ED treats the acute problem and had not been involved in long term planning to prevent frequent visits. Sharing this best practice can help other ED’s facing this similar problem. Implications for the future include the ability to generate and store care plans electronically.



Repository Posting Date:
21-Dec-2011
Date of Publication:
21-Dec-2011

Full metadata record

DC FieldValue Language
dc.titleConnecting the Dots: Multidisciplinary Care Planning in the Emergency Departmenten_GB
dc.identifier.urihttp://hdl.handle.net/10755/198300-
dc.description.abstract[ENA Annual Conference 2011 - Evidence-based Practice Presentation] Connecting the Dots: Multidisciplinary Care Planning In the Emergency Department<br/><br/>Purpose: To improve patient safety, quality and continuity of care for ED patients seeking emergency care more than once per month. To improve care coordination that promotes utilization of more appropriate external resources and to reduce caregiver stress associated with the care of this population.<br/><br/>Design: Patient safety and staff satisfaction initiative<br/><br/>Setting: Urban teaching, 52,000 visits, non trauma hospital.<br/> <br/>Participants: All patients seen in the ED more than once per month. The Multidisciplinary care planning team consists of the ED Clinical Manager, Physicians, Staff Nurses, Case Management, Social Services, Psychiatry, Risk Management, Inpatient Nursing, Hospitalist and Primary Physicians.<br/><br/>Methods: An electronic patient tracking system is used to collect data and systematically identify the high utilizer patient population. The data is analyzed and prioritized by the team to initiate a care plan intervention. This analysis lead to the realization that many patients in this group are complex and require individualized care. One size does not fit all. The number of patients identified thus far exceeds 200 patients. Once a patient has been selected, a care conference with the multidisciplinary team is organized. The case is presented and a discussion follows. Each discipline contributes a recommendation to building the individualized care plan such as: Psychiatry evaluations, behavior modifications, medication regimen changes, primary care establishment, appointments and home care services. Primary care physicians are involved in the process by attending the meeting or through telephone consultation with team members. The patient is also part of this process. Recommendations for care are discussed during admission or provided in a letter mailed to their home for outpatients. Care plan communication is also provided to primary physicians, hospital staff and stored in the medical record. <br/><br/>Results/Outcomes: Establishing a consistent, multidisciplinary model of practice will serve as a catalyst for a culture change in which clinicians assess, plan, intervene and collaborate with primary physicians to transition care to the community. Care planning is a resource intensive process requiring many partners to design and implement a therapeutic plan of care with appropriate resource management that includes strategies that staff can implement. This process guides the team to appropriate interventions and promotion of positive health outcomes that reduces the need for ED visits. Communication is improved between all stakeholders because there is a shared plan and common goal. The data shows that there has been reduced visit frequency for those that have formalized multidisciplinary care plans. Staff nurses were frustrated with the fragmented care and increased visits but now express that they are part of the solution, having direction with a plan in place.<br/><br/>Implications: Multidisciplinary care planning is resource intensive but provides the much needed missing link in healthcare. Historically the ED treats the acute problem and had not been involved in long term planning to prevent frequent visits. Sharing this best practice can help other ED’s facing this similar problem. Implications for the future include the ability to generate and store care plans electronically.<br/><br/><br/><br/>en_GB
dc.date.available2011-12-21T12:45:21Z-
dc.date.issued2011-12-21T12:45:21Z-
dc.date.accessioned2011-12-21T12:45:21Z-
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