Building Strong Community Relationships
Ensuring that our patients get efficient and effective care across the continuum requires a strong partnership with the communities we serve. Kari Evans, Post-Acute Care (PAC), Transitions of Care (TOC) Nurse for Dignity Health’s Care Coordination team in Arizona, has been working hard in her community to do this by addressing hospital capacity and placement…
Ensuring that our patients get efficient and effective care across the continuum requires a strong partnership with the communities we serve. Kari Evans, Post-Acute Care (PAC), Transitions of Care (TOC) Nurse for Dignity Health’s Care Coordination team in Arizona, has been working hard in her community to do this by addressing hospital capacity and placement challenges. Here we share just a few of the wins on her impressive list of accomplishments this year.
Managing Hospital Capacity
In April, Evans was asked to meet with the Arizona Surge Line, Arizona’s COVID Patient Transfer Center Line, and Dr. Lisa Villarroel, Medical Director of Public Health Preparedness, to share challenges hospitals are facing regarding bed capacity and post-acute placement to help them expand the Surge Line and address these capacity issues. During the meeting, Evans shared several key post-acute barriers to placement, including:
● A communitywide lack of information regarding who can take patients with COVID.
● Limited capacity of facilities willing to take COVID patients.
● A lack of clarity around current requirements, leading to poor placement options and increased length of stay.
● A time-consuming manual process that required weekly surveys and phone calls.
Based on this groundwork, a task force was created, which Evans worked on to help develop a variety of programs and initiatives, including:
● A Post Acute Care Capacity Tracker (PACCT) using GIS technology to help identify post-acute facilities throughout the state accepting COVID patients. The tracker now has over 250 facilities and agencies documenting daily COVID active and COVID recovered capacity and admission requirements.
● Providing information that led to Governor Executive Orders written to assist with throughput, consistency on SNF COVID admissions/isolation criteria, and a requirement to enter data into the PACCT database daily.
● Educating Leadership Teams on the PACCT dashboard to assist with COVID discharges and manage the dashboard access for the local market.
● Participating in weekly calls with the physician leaders from ADHS and other key post-acute leaders to share continued hospital discharge challenges and post-acute placement needs that led to new projects and Governor Executive Orders.
● Escalating challenging post-acute facilities to ADHS key leaders, who could then investigate and provide education to facilities that were refusing to take their residents back or enforcing extreme requirements.
Supporting a SNF Pilot
Evans assisted with a COVID capacity pilot project which allowed Dignity Health to place patients needing SNF level of care who were still in their isolation period (10-20 days) but stable for discharge, bypassing some of the red tape that most SNFs require for COVID admissions. Evans helped implement the pilot, provided ADHS with feedback, and engaged and educated Dignity Health Care Coordination teams on the project, which has been expanded to all hospitals statewide.
Aiding in Disaster Planning
Evans also aided in disaster planning at the local level, including:
● The Apria DME surge plan, a plan to have oxygen vans at each campus to allow liaisons to restock oxygen to expedite discharges and open bed capacity sooner during the surge in late June and early July.
● HSAG weekly calls, to provide updates on our challenges and efforts at the hospital level, and ways our post-acute teams could assist with the challenges.
● Weekly Incident Command calls, providing updates for the East Valley Hospitals regarding ongoing barriers and solutions.
“Kari has done some incredible work in the last six months in the community with PAC and the state surrounding COVID,” says Barbara Brownell, MSW, Director of Post-Acute Care Operations, Care Coordination, at Dignity Health. “We appreciate her dedication to advocating on our behalf and to ensuring our patients receive the care they need when they need it most.”
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