prioritizing the sash world
TRANSCRIPT
Prioritizing the SASH World Amy Perez, SASH Statewide Support Coordinator
Kristi Poehlmann, RN, SASH HSE & Nurse Consultant
Melissa Southwick, , SASH Statewide Support Coordinator
1. Objective
2. Roles and Responsibilities
3. What is SASH?
4. Staff tasks by Intervention Area
5. Flow chart for prioritization
6. WN/SC Meeting Guide
7. Principles of Prioritization
8. The Big Picture
9. Q&A
The tools you use to effectively manage your panels so your panels don't manage you.
Agenda
Objectives
• At the end of this session you will be able to –
1. Describe shared priorities between the SC & WN
2. Describe the purpose of the weekly SC & WN meeting and how to have this type of meeting
3. Describe priorities within your SASH Panel
4. Describe the tools that are available to you to help you prioritize your SASH Day and Panel Activities
Roles/Responsibilities
• Put your Post-It notes on the tasks that you are responsible for.
– **DON’T WRITE ON YOUR POST-IT NOTE – WE WANT TO LOOK AT COLORS. THANKS!
What is SASH (in one sentence)?
SASH harnesses the strengths of social service agencies, health providers, non-profit housing organizations and the SASH
participant to work together to support Vermonters to live safely and healthfully at home.
Our SHARED GOAL as the SC/WN Team
The SASH Model Focuses on Three Components of Care Management
6
• Coordinates with discharge staff, family and neighbors
• Personal visit to review discharge instructions
• Helps ensure a safe home transition
Care Coordination
• Develops healthy living plan
• Coaches SASH Participants
• Provides reminders and in person check ins
• Organizes presentations and evidence based programs
Self Management
• Conducts wellness assessment
• Convenes SASH team
• Understands participants needs and preferences
• Coordinates individual/community healthy living plans
Transitional Care
How does SASH deliver those 3 Components?
Person-centered
SASH Staff embedded in
housing
Formal Partnerships
Information Sharing
Prevention and Wellness through Data-driven Healthy Living Planning
SASH Staff Tasks by Intervention Area SASH Coordinator Wellness Nurse
Transitions Support
and Coordination
Communicates with discharge staff at hospitals
and skilled-nursing facilities
Attends discharge planning meetings
Communicates with family members/support
persons
Visits SASH participant to review discharge
instructions
Coordinates with SASH team to help facilitate a
safe transition home
Communicates with SASH team and family members regarding
transitions home
Visits SASH participant at home as soon after discharge as
possible
Works with SASH team to coordinate regular check ins and/or
medication reminders as needed
Updates Participant record with new medications or
treatments as appropriate
Self-Management Develops Community Healthy Living Plan (CHLP)
with SASH team
Provides individual and group encouragement to
SASH participants in meeting self-management
goals
Provides regular reminders and/or in-person
checks with SASH participants as needed
Organizes educational presentations and evidence
based programs
Provides individual home visits to high risk SASH participants
Assists SASH participants in setting up medication
management systems
Provides individual and group preventative interventions such
as blood pressure checks and weight monitoring
Provides information and education on self-management
strategies
Coordinated Care Coordinates with Nurse to schedule SASH
assessment for SASH participants
Convenes SASH Team meetings
Conducts individual person-centered interviews
Develops individual Healthy Living Plans (HLPs)
Supports SASH participants in meeting their HLP
goals
Conducts SASH assessments
Participates in SASH team meetings
Supports participants to meet their HLP goals
Identifies level of risk among SASH participants
Introduction
• Setting Priorities - essential and critical thinking skill
• Priority setting is perhaps the most critical skill in good time management, because all actions we take have some type of relative importance
• Management of a SASH Participant load depends heavily on setting priorities
Time Management
• Three Basic Steps in Time Management
– Allow time for planning and establish priorities
– Complete the highest priority task whenever possible and finish one task before beginning another
– Reprioritize based on the remaining tasks and on new information that may have been received
SASH Coordinator Day HOW TO PRIORITIZE THE SASH COORDINATOR’S DAY
Priority #1 – ALL SCHEDULED VISITS
Priority # 2- Scheduled SC Programming
Priority #3 – SASH Participants having a
problem/ongoing issue. Prioritize the following according to severity of
discussion between WN/SC:
Weekly SC/WN Collaborative meeting NEW SASH Assessments SASH Re-Assessments Person Centered Interview visits HLP sessions
These scheduled offerings are documented on the SASH Flash and/or monthly Calendar.
Cancelling last minutes decreases the future success of other SC programming.
Participants who have recently had transitions: from hospital/rehabilitation/skilled nursing home/Emergency Room (SCs have 48 hours to attempt contact once the participant returns home.)
Participants who have had a recent fall Participants who have had a major health change or new
diagnosis, therefore may need health education, referrals and/or support
Participant to whom you provide regular reminders and/or in-person check-ins
Participant experiencing life changes, recent loss, change in health status, who are having difficulty coping effectively (mental health issues)
Participants whom you are providing support with HLPs
Consider establishing two types of office hours Participant office hours where you can
redirect “frequent fliers” who come to your office to discuss the same issue daily.
SC office hours where you have planned “door closed” time to work on: o Document your encounter
notes (if it’s not documented it didn’t happen)
o Developing your Community Healthy Living Plan
o Organizing and communicating the agenda for your SASH team meeting
o Developing your SASH FLASHo Recruiting and supporting
volunteerso Time to provide caregiver/
family support as neededo Work on learning evidence
based programs you will offer to your participants.
Plan to be flexible: This may sound like an oxymoron but a
schedule that is too tight or too rigid will make it very difficult to be flexible. Remember that you are are working with people, and people are unpredictable. If you leave some “wiggle room” in your schedule each day you will more likely be able to attend that unforeseen discharge planning meeting, or help out when the ambulance arrives. If nothing arising during this flexible time in your schedule see about SC office time for ways to fill it.
Wellness Nurse Day
Priority #1 – ALL SCHEDULED VISITS
Priority # 2- SCHEDULED – A. Blood Pressure Clinic
B. Wellness Programming
Priority #3 – SASH Participants having a
problem/ongoing issue. Prioritize the following according to severity of
discussion between WN/SC:
HOW TO PRIORITIZE THE SASH WELLNESS NURSE DAY(S)
Weekly SC/WN Collaborative meeting NEW SASH Assessments SASH Re-Assessments WN 1:1 visits previously scheduled as
follow-up HLP sessions
These scheduled offerings are documented on the SASH Flash and/or monthly Calendar.
Cancelling last minutes decreases the future success of other WN Programming (clinical or
wellness presentation).
Participants requesting to see the Wellness Nurse –
please note the clinical or care coordination rationale for the nursing visit.
Participants who have recently had transitions: from
hospital/rehabilitation/skilled nursing home/Emergency Room
Participants who have had a recent fall
Participants who have had a major health change or new
diagnosis, therefore may need health education and/or referrals
Participants who have recently seen their primary care
provider or a specialist and would like follow-up with the Wellness Nurse
Participant with chronic conditions who requires
Wellness Nurse evaluation – i.e. vital signs, lung sounds, weight evaluation, medication management
Participant experiencing life changes, recent loss, change
in health status, who are having difficulty coping effectively (mental health issues)
**PLEASE NOTE – Wellness Nurses cannot see residents
that have not signed up with SASH. (this is an opportunity)
Priority #3
Is this a medical emergency?
Is this an Urgent Care need?
For Priority #3 – Always consider the following questions -
Call 911
Refer participant to
call PCP or go to Urgent Care
Obtain discharge paperwork and scenario
in order to brief WN. Is this a transition?
Is this a fall?
Obtain description of fall and how it transpired,
level of medical attention sought.
Is this a post – PCP or specialist meeting request?
Obtain the AFTER Visit Summary
Is this a Chronic Condition follow-up?
Discuss any Wellness checks or interactions with participants since
last visit
Is this a major health change/life change/recent loss/change
in health status?
Obtain Chief complaint for discussion with WN
Enter Green colored bubbles into JotForm
Review SC/WN Guide (hand-out)
Additional Principles of Prioritization
• Know the needs and priorities of your SASH Participants and Panel – This is rationale for the weekly SC/WN meeting
– Nurses will be able to identify participants needing to be seen first.
– After the WN assessment is completed – the WN and SC can discuss participant needs in terms of priority (i.e. needing to see the PCP today vs working on transportation, needing prescriptions vs attending the walking program)
Additional Principles of Prioritization, continued
• Consider all factors –
– What things can be delegated to others
– How much time is involved in some visit types (some visits take more time)
• Always remain flexible
– EVERYDAY, priorities need to be re-evaluated, reorganized depending on SASH panel changes
– i.e. hospital admissions, discharges home, falls, etc that impact your day to day operating schedule
Additional Principles of Prioritization, continued
• Use of Creativity –
– Emphasize patient’s abilities and strengths so that they may learn to assume MORE self-management of their conditions
– Encourage family participation (when possible) in care
Priority Setting Traps
• “Whatever hits first”
• “Path of least resistance”
• “Squeaky wheel”
• “Default”
• “Inspiration”
Simple Suggestions
• Procrastination –– 3 most common reasons are: – Not wanting to begin
– Not knowing where to begin
– Not knowing where to begin, even if you wanted to do, which you don't.
• Poor planning
• Failure to establish goals and objectives
• Inability to delegate
• Inability to say no
• Management by crisis
• Haste
• Indecisiveness
Time Wasters
• Group Programming
• Document as soon as possible after an activity is completed.
• Schedule tasks when the time is right
THE BIG PICTURE – WHAT’S THE RESULT?
What data looks like NOW Chronic Conditions
Data Collection -> Community Healthy Living Plan -> Monthly Offering & Individualized Healthy Living Plan
KEY Take-Aways
• Communication
• Organization
• Collaboration
• Delegation
• Follow-up
Questions?