A Closer Look at Trinity Health’s Integrated Care Coordination System
Care coordinators can help hospitals better manage care through an integrated system that provides best practices in the handover process.
For example, Trinity Health in Livonia, MI, created a care coordination tool to ensure the most effective care. It is adapted from the Agency for Healthcare Research and Quality (AHRQ) TeamSTEPPS 2.0. (Find out more about TeamSTEPPS at: http://bit.ly/2GqG0mv.)
The following are some sample items from Trinity Health’s two-page handover process SBAR (situation, background, assessment, recommendation/request) guidance:
• Situation:
The guidance suggests questions to consider in one column, and their descriptions in an adjoining column. Here are a few examples:
- What are the current situation and overarching concerns? “Describe specific situation. Include code status. Be concise and concrete,” according to the guidance.
- What are key, recent changes to the patient’s health status? “Determine the current opportunities and/or challenges.”
- What is the patient’s level of risk for poor outcomes? “Utilize standard risk stratification methodology.”
• Background:
- What are the relevant comorbid conditions? “Highlight the comorbid conditions that place patients at risk.”
- How does the family history impact the plan of care? “Share applicable family history.”
- Does the patient have a support network? “Include family and caregiver dynamics.”
• Assessment:
- What are the pertinent biometrics — the pertinent, critical, and pending labs, diagnostics, or medications? “Communicate clinical information, as applicable.”
- What are the safety concerns? “Highlight allergens, falls, isolation, socioeconomic factors.”
- Is the patient able to self-manage? “Consider health literacy, cultural factors, social determinants (food insecurity, transportation, housing, medications).”
• Recommendation and Request:
- What is the recommended plan or the next steps? “Respect patients’ preferences and goals of care.”
- What actions will be taken to ensure a safe transition? “Clarify expectations. Ensure there is adequate time allowed in handover process to ask/answer questions.”
- How will the next site of care connect with the previous site of care if further questions arise? “Communicate follow-up contact information.”
Care coordinators can help hospitals better manage care through an integrated system that provides best practices in the handover process.
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