Massachusetts STAAR Learning Session October 2011
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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:
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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:
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:
|
|
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:
|
|
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
| |
| 3:30-3:45PM |
Transition to Plenary |
| 3:45-4:15PM |
Next Steps and Closing Reflect on our plans for achieving results and discuss next steps in STAAR. |
| 4:15PM |
Adjourn |