Patient Engagement
through Patient Centered
Goals
Chris Walker
MSN, RN, MHA
St. Cloud Hospital/CentraCare Health
Typical Transition Failures
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Self-care
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Care Planning
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Health Literacy/Communication
Improvement Strategies
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Self-care
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Care Planning
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Health Literacy/Patient-Provider
Communication
Illness Management & Recovery
(IM & R)
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Psychoeducation
Behavioral tailoring for medication adherence
Relapse prevention training
Coping skills training
Social skills training
Recovery Goals
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Unique to each individual
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Must be personally meaningful
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Vary from modest to ambitious
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Use of Motivational Interviewing (MI)
Unique Treatment Plan (UTP)
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Criteria and types
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Plan development with patient and
interdisciplinary team
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Electronic health record access
Interdisciplinary Staffing Note
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RN/SW Communication
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Plan of care
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Payor
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Suicide risk assessment
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Event changes
Illness, Management & Recovery (IM & R)
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Recovery goal
Dialectical Behavior Therapy Protocol
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Behavioral Chain Analysis
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Diary card
Integrated Dual Disorder Treatment (IDDT)
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Staged within 3 days of admission
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Stages of mental health and/or substance use
Transition Plan
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Disposition needs
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Medical follow up
Day of IP stay
UTP (yes/no)
Violence risk assessment
Family meeting
Bedside Shift Report
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Warm handoff
SBAR report
Focused pt and safety assessment
Review of tasks
Identify patient and family needs/concerns
My Care Board
Managing My Recovery
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Relapse prevention plan
Reasons for living
Possible triggers
Early warning signs
Support people
Recovery goal
Strategies for success
Discharge Checklist
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Specific to disciplines
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Improved consistency
Transforming Care at the
Bedside (TCAB)
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Purpose
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Rapid change cycle (PDSA)
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Positive culture change
References
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www.rarereadmissions.org
Nurse Bedside Shift Report. June 2013. Agency for
Healthcare Research and Quality, Rockville, MD.
http://www.ahrq.gov/professionals/systems/hospital/e
ngagingfamilies/strategy3/index.html
Meyer, P. & Gingerich, S. (2009). Supporting Illness
Management Recovery on Inpatient Units.
2007: Robert Wood Johnson Foundation & Institute
for Healthcare Improvement. TCAB Communications
Guidelines