Speaker
Description
The learning objective for this gap was to establish the baseline data for our home as most of the work for a transition is done prior to admission of the resident.
Once baseline data was determined key areas of improvement were identified as communication, education and documentation.
• 1 Communication
• Improve communication with residents and families prior to admission using phone calls and emails to answer questions and advise families of list of items to bring with them.
• Improve communication of options available to families particularly in circumstances where OHH provides limited notice of admission dates
• Improve collaboration between Social Workers, BSO and Registered staff to determine care needs prior to admission.
• Improve collaboration between Social Workers, BSO, Registered staff and resident to determine appropriate transition plan.
• 2. Education
• Improve education to families of services available within the home
• Increase opportunities for families to ask questions
• Education of registered staff regarding expectations for documentation about education provided to resident and families
• 3. Documentation
• Documentation in PCC changed to include sections to chart on education provided to residents and families.
• Documentation in PCC changed to include opportunity to discuss admission transition with families at post care conference.
• Improve documentation within the existing forms to make the Transition gap sustainable
• Improve expectation for documentation of phone conversations with other facilities
• Sharing information learned about residents with the next Facility
Outcomes
Still a work in progress, limited admissions during timeline after changes.
Residents expressing appreciation for use of Social Workers prior to admission to ease transition. Families expressing appreciation for attention to details from staff.
Issues identified from OHH could also discuss during initial contact
Sharing of information: opportunities available to improve the next transition for residents and families
Author(s) Credentials and Title
Serina Alberts-Bourgeois RN
What RNAO BPG or tool/toolkit is your abstract related to?
Transitions in Care
| Organization Name | Watford Quality Care Center |
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