Transition Management Office-Project Overview Report
August 21, 2013 –Listed based upon expected impact to patient care and readmissions
Key Aspects/
Key Points of Interest
Project
Transition Huddles
(Scope: VUH)
One Medication List
(OML)
(Scope: Enterprise,
excluding VPH)
Current: Neuro/NSG, trauma, VHVI, medicine hospitalist,
heme/onc, urology, geriatrics, vACT (ortho), pulmonary, MICU

PFO initiative

vACT

Launching soon: SICU, burn, ortho trauma, colo-rectal


Incorporating clinics into huddle utilizing facetime
Liaisons: VHCS, PBPRI, VSRH,
Walgreens Infusions

Operationalizing earliest date of discharge into workflow

Across VUMC: VUH, VMG, MCJCHV

My Health Team- CMS Award

Developing standard process, roles, responsibilities,
accountabilities, and tools which allow for measurement

Pioneer

Meaningful Use
Scope: Correct list, optimized list, patient friendly list,
staff/faculty education, patient education, campaign

Informatics Department

Current work: ED design complete, Anesthesia & Scheduled
Surgery design in-progress
Outpt. standard operating
model

VMG-Outpatient clinics

Inpatient & Outpatient care coordination, based on disease

Outpatient My Health Team

Inpt: AMI, CHF, COPD, PNA; OutPt: CHF, HTN, COPD, DM

VHVI

Goals: 25% readmission reduction, physiological disease
control, improved utilization, cost reduction

Informatics

EDW

Across VUH/Adult VMG and 3 affiliates: NC, WMC, MRMC

Transitions Task List

Evaluation of needs and review of available
systems/technology

Informatics

CMS-MHT



My Health TeamCMS Award
(Scope: VUH, VMG,
and 3 affiliates)
Task List Mgmt and
Communication Tool
(CareInSync)
Intersections with Other
Initiatives/Departments

Development of design requirements

Readmissions, LOS outliers & Post Acute Care

Dept of Finance (EDW)

AllScripts Integration into the EDW

VHAN
(Scope: Enterprise)

Referral patterns
Post Acute Care

Readmission Coalition

CMS- (IMPACT/INTERACT)

Data/reporting

Dept Finance (EDW)

Virtual Case Management & Transitional Care Team (SWAT)management of complex & long stay patients

VHAN


Continued growth in affiliation with post-acute facilities
Vanderbilt Home Care
Services

Roll-out of VHCS Central Referrals for home services

Payment includes financial & performance accountability for
an episode of care (3 days prior to procedure and extending
90 post discharge)-- Scheduled to go “at risk” October 1, 2013

Post Acute Care

CMS-MHT

Transition Huddles
Risk Mitigation strategies include: Pre-op assessments,
Multidisciplinary planning conference, Care Coordination,
Patient Engagement, Personalized Pathway, PAC Handovers
and Referring MD Engagement

OML
(Scope: Enterprise)
Data & Dashboards
(Scope: Enterprise
and Post-Acute Care
Facilities)
Valve Bundle -- CMS
Bundled Payment for
Care improvement
initiative

(Collaboration w/VHVI)
(Scope: VHVI inpt &
outpt)
TRANSITION MANAGEMENT OFFICE
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Key Aspects/
Key Points of Interest
Project
CM/SW Redesign

Review/redesign of current service-based model
(Scope: Enterprise)

Integration of transitional care modalities
Vanderbilt Stallworth
& VUH Quality
Improvement Project

Intersections with Other
Initiatives/Departments

Nursing, Physician Services
Rapid cycle assessment via 4-sessions -- frontline staff from VUH
& VSRH

VSRH: CM, SW, Admitting,
Liaisons, Physician

Mapping of current state (Eval of needs  admission at VSRH)
including roles, responsibilities, tools, strengths, and barriers.

VUH: CM, SW, Nursing, PT/OT
(Scope: VUH & VSRH)

Frontline staff and sponsor level recommendations and priorities
Patient Flow
Initiative: Discharge

Earliest date of discharge documentation

PFO Project

Earlier discharge planning--planned admissions/Elective
Procedures

VMG-Clinics

Pharmacy
(Scope: VUH & Adult
VMG)

Discharge medications

Project Commodore

Objective: Creation of a clinical protocol communications
package to improve the care experience while reducing the
cost of care

CMS Award (MyHealthTeam)

Informatics

EBM/Quality
(Scope: TBD)
Standardizing
Diagnosis Based
Education

Pilot with CMS MyHealthTeam population (anticipated– 1/2014)

Automated communication solutions between care
coordinators & patients

Focus Areas: CHF & Diabetes

VMG/Outpatient Teams

CHF: content identified, operationalized plan for incorporating
into bedside RN workflow, PDSA cycles established, and
actively engaging providers in edu. plan

VHVI team

Home Health

Diabetes team
(Scope: VUH, Adult
VMG, VHCS)

Developing plan to roll education materials across all services

Patient Education

Clearly outlined template to be utilized for diabetes education

Patient & Family Engagement
Community Initiative

Attended Congregational Health Network training session

VHAN

Engaged with Lipscomb Univ. Center for Transformaging Dept.

Patient & Family Engagement

Establishing community/congregations interest in participation

Considering alternative funding sources

Ground swell of enthusiasm around work from VUH staff

Working with VHAN team as strategy for population Mgmt

Process maps of inpatient (CHF) and VHCS workflow with gap
analysis and opportunities identified

IT

VHCS

ROI completed

MyHealthTeam/CMS

New populations & volumes identified that may benefit

VHAN

Recommendations for operationalizing rollout of program
including benefits for population mgmt & MyHealthTeam

Project Commodore



vACT
CMS Award- SNF (INTERACT/IMPACT)
Meaningful Use (transition related aspects: Summary of Care, Discharge Summary, Functional Status,
Care Plans, etc.)
(Scope: TBD)
Telehealth
(Scope: TBD)
Additional Major
Intersections/
Partnerships
TRANSITION MANAGEMENT OFFICE
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