An Introduction to Safe Transitions for Patients to New Appointments

Slide 1: An Introduction to Safe Transitions for Patients to New Appointments

Ambulatory Care Facility Team Presentation

Image: AHRQ Logo; the logo appears in the lower right corner of all subsequent slides.

Slide 2: Overview

• Purpose and Benefits.
• Toolkit Components.
• Team Member Roles and Responsibilities.
• Implementation Steps.
• Resources.

Note: In these slides, we review the purpose and benefits of using the project resources, the toolkit components, your role and responsibilities as a member of the team, the recommended implementation steps, and additional resources available to supplement your work.

Slide 3: Purpose and Benefits

• Transitions of care can be complex and challenging for many patients.
• By preparing and engaging patients for new ambulatory care appointments, you can potentially:
  • Reduce errors.
  • Increase patient engagement.
  • Take actions to ensure patients have the information they need.
  • Improve coordination.
  • Enhance overall patient experience.
  • Improve communications.

Note: Research has shown that the process of transitioning from one health care setting to another is vulnerable to patient safety gaps, in part due to a lack of effective communication. These gaps have the potential to cause patient harm and safety errors, including increased hospital readmissions. Patients who require appointments with other clinicians are more vulnerable to patient safety errors. Evidence has shown fewer adverse events when patients and their family or friends are engaged as active partners on the health care team rather than passive receivers of care.

By preparing patients for new ambulatory care appointments, you can potentially:

• Reduce errors related to transitions of care.
• Increase patients’ engagement in their own plan of care.
• Address requirements related to ensuring patients have the information they need.
• Improve coordination of care for patient.
• Enhance overall patient experience.
• Improve communications among patients and care partners and other ambulatory care facilities.

Slide 4: Toolkit Components

• Guide for Safe Transitions to New Appointments.
• Checklist to Prepare Patients for New Appointment.
• Appointment Aide: Preparing for Your Appointment.
• Pre-Intervention Assessment (PIA).
• eam Training PowerPoint Video.

Note: The toolkit has 5 components—

• A written toolkit guide, with in-depth instructions on how to use the toolkit as well as useful resources. It is entitled: Guide for Safe Patient Transitions to New Appointments.
• The Checklist to Prepare Patients for New Appointments, a set of best practices team members should follow with every patient.
• Appointment Aide, which is a tool for patients to reference and use at the current appointment, and then take with them to the new appointment.
• The Pre-intervention Assessment, also called the PIA, which the team lead and/or team members should complete at the start of implementation.
• And finally, the narrated PowerPoint video, which you are viewing now.

Slide 5: Team Lead’s Role and Responsibilities

The team lead is expected to provide oversight for the project by:

• Reviewing the toolkit.
• Assessing the facility’s current practices to determine which parts of the toolkit to use.
• Educating other team members.
• Working with the team to plan toolkit implementation.
• Evaluating and making changes as needed.
• Finding ways to make the toolkit sustainable.

Note: The team lead for this project plays an important role in providing oversight. If you plan on implementing the toolkit, you must have a team lead. Who is the team lead at your facility?

In order to provide this leadership, the team lead needs to review the toolkit and be available as an expert to answer questions and maintain momentum.

In addition, the team lead assesses your facility’s current practices to determine which sections of the toolkit to use, educates other team members, works with the team to decide how to implement the toolkit, and coordinates evaluation and sustainability efforts for the project.

Slide 6: Team Member Roles and Responsibilities

Team members are expected to:

• Review the Appointment Aide and Checklist to Prepare Patients for New Appointment.
• Collaborate with your team to determine how to use the tools and resources.
• Use the Appointment Aide with patients who will transition to new clinicians.
• Participate in evaluations of the toolkit.
• Consult your team lead and/or the toolkit guide if you have additional questions.

Note: Team members who are responsible for patient and family engagement and ensuring patients have safe transitions to new appointments should be involved in this work. Who in your facility has responsibilities and interests in patient and family engagement and safe transitions of care?

Team members also have specific roles and responsibilities in order to ensure success. All team members are expected to:

• Review both the Appointment Aide and Checklist to Prepare Patients for New Appointments.
• Collaborate with your team to determine how to use the tools and resources.
• Use the Appointment Aide with patients who will transition to new clinicians.
• Participate in evaluations of the toolkit.
• Consult your team lead and/or the toolkit guide if you have additional questions.

Your team lead is a valuable resource during implementation and can be consulted if any questions arise.

Slide 7: Implementation Process

Image: Nine text boxes are in a sequence, arrows pointing from one to the next:

• Step 1: Identify Leader.
• Step 2: Engage Team.
• Step 3: Complete PIA.
• Step 4: Identify Patients.
• Step 5: Begin Using Toolkit.
• Step 6: Integrate Toolkit.
• Step 7: All Staff Use Toolkit.
• Step 8: Use Reference Materials.
• Step 9: Evaluate.

Note: There are nine steps in the implementation process.

Slide 8: Implementation Steps

Step 1: Identify Leader.

Identify a leader or champion.

Step 2: Engage Team.

Engage all team members who are responsible for supporting patient engagement and safe transitions of care.

Note: In the following slides, we will review the step-by-step instructions for this project.

In Step 1, the team lead reviews the toolkit guide. Prior to implementing any changes, the team lead consults this toolkit guide to understand how the toolkit can be used to help your facility identify and address any opportunities for improvement. Team members are encouraged to also review this toolkit guide while implementing materials. The Guide provides additional details concerning each step.

In Step 2, the team lead completes the Pre-Intervention Assessment. You may be asked to help complete this assessment. The goal is to obtain an accurate reflection of your facility’s current practices relative to:

• Identifying patients who might benefit from using the tools.
• Engaging patients and their family members or friends assisting with care.
• Ensuring safe transitions of care to other clinicians.

Slide 9: Implementation Steps

Step 3: Complete PIA.

Complete the PIA tool.

Step 4: Identify Patients.

Identify which patients may need additional support in order to prepare for a new appointment.

Notes:

In Step 3, the team lead will determine opportunities for improvement by using the PIA. This step determines which resources can help you address gaps in patient engagement and safe transitions of care. The results of the PIA can be used to guide the implementation of the toolkit.

In Step 4, it is important to identify which patients may need additional support in order to prepare for a new appointment. Once the team is aware that the patient has a new health care appointment, you can use an existing or new risk assessment to determine which patients may need support to prepare for their new appointment. Multiple factors, such as patient load, patient characteristics, and existing processes, may influence how you decide which patients need additional support.

Slide 10: Implementation Steps

Step 5: Begin Using Toolkit.

Begin to share the Appointment Aide.

Step 6: Integrate Toolkit.

Integrate Toolkit into workflow.

Notes:

In Step 5, the team begins to share the Appointment Aide and Use the Checklist to Prepare Patients for New Appointment by identifying a small group of patients or clinicians that would benefit from using the Appointment Aide and the team tools. After successfully implementing the tool with a small group of patients or clinicians, consider how you might increase the number of patients who may benefit from use of the Appointment Aide, and how the tool could be better incorporated into day-to-day processes.

The Appointment Aide includes questions and prompts to help the patient prepare for a new ambulatory care appointment by discussing and documenting information concerning medications, appointments, key contacts, and signs and symptoms. When giving the tool to the patient, explain that they can use the Appointment Aide to keep track of and communicate their concerns, questions, and preferences, and to take notes on important aspects of their care. If a care partner is with the patient, hand the care partner page directly to the care partner and encourage them to use the questions to address their needs.

In Step 6, you will begin to integrate the toolkit into the workflow. Patient safety, especially during transitions of care among clinicians, is impacted by how teams manage workflow and communicate information. In ambulatory care settings, all health care team members, including physicians, nurse practitioners, physician assistants, health education coaches, and pharmacists should be engaged, and their responsibilities should be aligned with a team approach in transitions of care and patient engagement.  

The Team Lead will work with you and your team to determine when to share the Appointment Aide tool with the patient and use the accompanying Checklist to Prepare Patients for New Appointment. Discuss with the team the best ways to integrate the tools into existing workflows and who on the team should be part of each of the key activities. The toolkit guide outlines suggestions in more depth.

Slide 11: Implementation Steps

Step 7: All Staff Use Toolkit.

Roll out the toolkit to the whole team.

Step 8: Use Reference Materials.

Use resources and other supplementary materials as needed to promote effective skills, knowledge, and confidence among all team members.

Step 9: Evaluate.

Evaluate use and benefits of tools and processes.

Notes:

Step 7 involves rolling out the toolkit to the whole team. Now that your facility has a strong process in place, you’ll start using the tool with more patients.

Step 8 use resources and other supplementary materials, as needed, to promote effective skills, knowledge, and confidence among all team members. Resources are provided in the Toolkit Guide, but don’t forget to use other resources available to you through your facility, including your team lead.

Regular evaluations are key to making changes that are beneficial to the team and your patients. In Step 9, your team lead will conduct evaluations to study the use and benefits of the tools, and what should be modified. Your feedback and suggestions will be valuable to improving how your facility uses the toolkit.

Based on the evaluations, the team lead will communicate any changes your facility has made to use or modify the tools to ensure success.

To ensure that the tools are sustainable, some key actions that your facility can take include:

• Integrating the toolkit into normal processes, such as team trainings, your electronic health records, and your effectiveness measures; this includes allowing extra time for using the tools if necessary.
• Rewarding the use of the toolkit.
• Regularly evaluating and making improvements to the interventions, as discussed in Step 7. This ensures that the toolkit is useful.
• Coaching the team on best practices.

The team lead and the facility manager can take steps to make the tools sustainable. If you have ideas or feedback on sustainability, be sure to communicate them to these individuals.

The comprehensive reference list in the toolkit guide is more than just the sources consulted to design this toolkit. It is a list of possible resources your team can use to gain additional knowledge, skills, and confidence when implementing this project or other QI projects in the future.

Slide 12: Summary

• This toolkit has strategies and resources to improve transitions of care and patient engagement for patients and their care partners.
• As a team member, you have an important role in implementing this toolkit.

Note: In summary, this toolkit has strategies and resources to improve patient engagement and transitions of care for patients in the ambulatory care setting.

The team lead plays a key role overseeing the project and any changes to address opportunities for improvement. As a team member, you have an important role in implementing this toolkit. As you begin to implement these tools, keep in mind that by engaging patients in their care and partnering to facilitate smooth, safe transitions, you can make a difference in the lives of the patients you serve.

Thank you for your commitment and support for ensuring safe, high-quality patient care in the ambulatory care environment.