realistic expectations and discussing palliative care needs might promote the need for advanced therapy and adherence of self-care and medication management. Budgetary Needs and Possible Funding The Maryland Health Services Cost Review Commission has awarded the Nexus Montgomery partnership program with $7.6 million to address the challenges affecting the health and safety of the county and to “implement or expand initiatives that will improve the health status of those most at risk of avoidable hospital use” ("Montgomery County Hospitals Announce Funding of Nexus Montgomery Regional Partnership," 2018). Timeline for Implementation and Evaluation Methods The Nexus Mo ntgomery program initat4d in 2018 and plans to implement success interventions and transition of care models throughout the county with a 5-year plan to begin with. The first year The Nexus Montgomery program partnered with six (6) local hospitals and strategized plans to recruit and organize ways to improve quality and care for the patients in the community. The program participants meet quarterly and monthly if needed to discuss progress and barriers. Each of the six hospitals have a set goal and target re-admission rate for each quarter, furthermore, these hospitals work in conjunction with preferred SNFs and home health agencies to ensure community and/or SNF discharges are effective and quality care is continued
AVOIDABLE READMISSIONS 11 throughout, all in effort to reduce readmissions. Hospitals and adjacent facilities that do not meet the target goals are offered 1:1 focused meetings to understand the barriers and help improve their outcomes. QSEN Competencies In 2003 Institue of Medicine (IOM) published a report called Health Professions Education , which highlighted the importance of healthcare quality and safety; this lead to the development of the Quality and Safety Education for Nurses (QSEN) and six (6) core “quality and safety program competencies that are essential in closing the gap between the quality chasm. These competencies are patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics” (Lyle-Edrosolo & Waxman, 2016, p. 73). In management of HF and reduce 30-day readmission rates it is important to recognize the need for teamwork, collaboration, and delivering patient-centered care. Teamwork and collaboration as discussed are crucial in the transition care model as patients require education, follow-up and support once they are at a community level or in an acute care setting. Patient- centered care is important as the multidisciplinary team should evaluate patient-specific barriers such as social, economical, or personal to implement effective ways in management thir disease process and improve quality of life.
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- Summer '16
- Kris Diggins
- Health care provider, Ejection fraction