Probably the longest standing project in the Hub, the Transitions Project seeks for ways to improve communication as well as patient care across a patient's stay at Sibley through their return home. The project seeks to change the replace the idea of a "discharge" with that of a "transition" to illustrate how care and support doesn't end once a patient leaves the hospital. As one of the largest projects as well in terms of team members, there are many initiatives that the team is pursuing to achieve these goals.
Sometimes information can fall through the cracks, which can make situations more difficult for patients and for the care team. To address this the team looked at tools that already existed as well as got feedback from physicians about what information would be needed to ensure that the entirety of a patient's needs were communicated. At this stage, the team has created a card for care members to use during their transition calls. The current version is shown to the left, but it is still in the prototype phase.
We recognize that a patient's health extend beyond their physical symptoms; it relates to a patient's home environment as well. Our first prototype for follow up has been to actually have a doctor and nurse do a home visit to the patient soon after leaving the hospital. These visits have already shown us so much about how what is communicated in the hospital may not align with the status of home. How can we collect this information and better help our patients?
Building on opportunities to start conversations with community organizations about how their services might be better integrated into the hospital, we thought this project was a great opportunity to build connections within this community. Through these connections we hope to create better continuity of care for our patients.
We have found that patients are very relieved to hear that their primary care physician is aware of their being in the hospital. To respond to this, we are looking for ways in either Epic (our electronic medical records system) or through another form of communication that we could quickly contact primary care physicians and get their responses to patients. Similarly, we have been trying to decipher what level of notification would be ideal, simply a "your doctor knows" or a "your doctor will be a part of our decision making" or maybe something else.