Abstract P866: Care Coordination, Bringing It All Together

• Published in: Stroke (1970) 2021-03, Vol.52 (Suppl_1), p.AP866-AP866
• Main Authors: Davis, Cecile, Erickson, Sheila, Royer, Diane, Rutherford, Wendy, DuBose, Briony, Herrera, Toni, Plume, Tracy, Cummings, Maira, Black, Kathleen
• Format: Article
• Language: English
• ISSN: 0039-2499; 1524-4628
• DOI: 10.1161/str.52.suppl_1.P866

BackgroundIt is challenging to quantify the soft elements of care, that often make the most difference in the long-term success of the patients’ recovery such as stroke knowledge, readiness for discharge, family involvement and patient support resources. The interdisciplinary team members document their specialty notes, however they are saved individually and in different sections of the EMR. The stroke team was challenged to create a process that pulls this data together. HypothesisWe hypothesized that combining interdisciplinary team documentation into a Stroke Care Coordination Note in the EMR, would empower the care team to modify the acute care plan and simultaneously communicate post-hospital needs in order to maximize patients’ transition and outcomes. MethodsThrough the engagement of Lean Six Sigma resources, the multidisciplinary team evaluated current processes and documentation to identify gaps. Tools utilized in facilitated meetings include; scope and critical success factors, SIPOC, process mapping, PARMI analysis, and brainstorming. Additionally, sensing sessions and GEMBA observations provided key insights into current state and engaged stakeholders. ResultsThe team created a Stroke Care Coordination Note in the EMR that consolidates interdisciplinary notes, demonstrates the stroke patients’ individualized plan of care and communicates post hospital needs. Post implementation, additional benefits have been realized such asease of use (one touch click), improved nursing communication during transitions of care, and improved communication with ancillary teams such as therapy and discharge planners. ConclusionA thorough assessment of the current state and gaps, Joint Commission requirements and engagement of interdisciplinary team members, led to the development of a Stroke Care Coordination Note. At any given time, this note can be activated, convey the patients individualized stroke plan of care in the EMR, and be accessed by the interdisciplinary team. The care team stated improved overall patient care and communication during transitions of care. The ease of the use of the note and additional realized benefits support future systemic implementation among additional disease processes and entities.