Massachusetts STAAR Learning Session October 2011 (with Presentations)

Massachusetts STAAR Learning Session October 11-12, 2011
Working Across the Continuum to Drive for Results!


Learner Objectives:

  • Learn about work underway by peers in the four key changes for improving care transitions
  • Engage a cross continuum team with active participation by all
  • Share promising work with faculty and peers and obtain input and new ideas for achieving results
  • Formulate a solid plan for accelerating your work
  • Strengthen connections with peers

Day 1 - Tuessday, Oct 11
8:30-9:00AM

Welcome and set the stage

  • Presenters: Pat Noga and Paula Griswold
9:00-9:45AM

Our Collaborative Progress and Working Across the Continuum

9:45-10:45AM

STAAR Cross-continuum Team Presentations

Presenting Teams:

10:45-11:00AM

Break and Transition

11:00AM-12:15PM

Ring of Knowledge Sessions

These are an interactive breakout sessions during which each team will have time to share:
1) what they are most proud of and 2) what they need help with - in the context of efforts
to execute on the four key changes. The goal is to share good ideas, identify challenges, and
get input from peers on how to accelerate improvement.

12:15-1:15PM

Networking Lunch

1:15-2:30PM

Breakouts:
Promising Strategies for Successful Execution:
What we are learning about "what to do" and "how to do it".

Breakout A:
Ensuring Post-Hospital Care Follow-up: How do we effectively and efficiently act on our assessment of post discharge needs and collaborate with patients, their families, and the community to transition patients home safely?

Presenting Teams:Facilitators:

Breakout B:
Health Literacy and Effective Teaching: What are the most powerful tools and strategies for redesigning and executing patient-centered teaching.

Presenting Teams:
  • Northeast Hospital Corporation
  • Beth Israel Deaconess Medical Center
    Presentation
Facilitators:

Breakout C:
Engaging Front-Line
Staff (in any setting)
and Your Cross
Continuum Team

Presenting Teams:
  • South Shore Hospital
Facilitators:

2:30-2:45PM

Break and Transition

2:45-4:00PM

Breakout Sessions: Promising Strategies for Implementing the STAAR Changes:
What are we learning about what to do and how to do it.

Breakout A:
Ensuring Post-Hospital Follow-up Care: How do we effectively and efficiently act on our assessment of post-discharge needs and collaborate with patients, their families, and the community (healthcare and support systems) to transition patients home safely?

Presenting Teams:Facilitators:

Breakout B:
Providing Real-time Handover Communication: What information do patient, families, and community providers need to know about their hospital stay and how can we reliably share it?

Presenting Teams:Facilitators:

Breakout C:
Engaging Patients and
Families: Learning to
work with patients and
families as true partners
in their own care.

Presenters:
  • Janice Foust
  • Richard Elliott
  • Lindy Alves
Facilitators:
  • Paula Griswold
    Rebecca Steinfield

4:00-4:15PM

Transition

4:15-5:00PM

Action Planning Time
Individuals will have spent time during breakouts on identifying ideas to test.
Each cross-continuum team will come together during the plenary to share
what they learned and identify two ideas to test upon returning home.

 

Day 2 - Wednesday, Oct 11
8:30-9:45AM

Ring of Knowledge part 2 (contd from previous day)

9:45-10:00AM

Transition to Plenary

10:00-11:00AM

Accelerating Improvement

Presenter:
  • Rebecca Steinfield

11:00-11:15AM

Break

11:15AM-12:00PM

Partnering with Pharmacy: A panel discussion on pharmacy interventions to reduce readmissions

Presentation

Panelists:
  • Saad Dinno, Acton Pharmacy
  • Timothy Fensky, Sullivans Pharmacy
Moderator:
  • Paula Griswold

12:00-1:00PM

Networking Lunch

1:00-2:15PM

Breakouts by Care Setting

Breakout A:
Creating an Ideal Transition to Home by Working with Clinical Office Practices, Home Health, and Community Agencies

Facilitators:
  • Gail Nielse
    Presentaion
  • Pat Kelleher
  • Helen Siegel
  • Amy MacNulty

Breakout B:
Completing the Transition to Skilled Nursing,
Acute Rehabilitation, and Long Term Care
Facilities

Facilitators:
  • Laurie Herndon, Massachusetts Senior Care
    Foundation Presentation
  • Kate Bone

2:15-2:30PM

Transition to Breakout

2:30-3:30PM

Special Topic Breakouts

Breakout A:
Using the INTERACT Tools to Improve Nursing Home Care

  • Laurie Herndon, Massachusetts Senior Care Foundation
    Presentation

Breakout B:
Working with Your Medical Home Initiative

Breakout C:
Making Tough Conversations Less Difficult: Helping Patients and Families with Advanced Care Planning

  • Christine McCluskey, Commonwealth Medicine,University of Massachusetts Medical School
    Presentation
  • Adele Pike, Visiting Nurse Association of Boston & Affiliates
    Presentation
  • Jane Pike Benton, MetroWest HomeCare & Hospice
    Presentation

Breakout D:
10th Scope of
Work: Moving
Forward Together

3:30-3:45PMTransition to Plenary
3:45-4:15PMNext Steps and Closing Reflect on our plans for achieving results and discuss next steps in STAAR.
4:15PMAdjourn