In collaboration with the Indian Health Service (IHS) and the Centers for Medicare & Medicaid Services (CMS), the Partnership to Advance Tribal Health (PATH) project work is supporting improvement efforts with care transitions for certified hospitals providing Emergency Department services. The primary goal is to identify systems in place to assure hospital transitions across the care continuum by December 31, 2022.

The Care Transition Aim has multiple measures to support this goal which have been placed into five groups:

  • Inpatient discharge planning and discharge follow up
  • Emergency discharge planning and discharge follow up
  • Emergency Severity Index (ESI) accuracy
  • Emergency Department throughput time
  • Left without being seen (rate and patient follow up)

Collaboration between IHS, CMS, and the Great Plains Area Office has been essential in order to support forward progress to reach the goals of these Aims.  Program Managers are supporting the service units to identify priority areas of improvement and provide resources/tools such as the ESI Decision Tree from the Agency for Healthcare Resource and Quality (AHRQ). PATH has also provided resources through a Learning and Action Network which provides Aim 3 education along with additional opportunities to ask questions to other facilities.

With baseline summaries established, the goal is to improve these measures over time as new changes and improvements in processes are implemented throughout the service units. PATH and Area Office will continue to support the service units in order to ensure the best care is provided to individuals.

Teresa Haatvedt, RN, BSN - Great Plains QIN SDTeresa Haatvedt,RN, BSN, PATH program manager, states, “Our hope is to improve care provided in the Emergency Department and to ensure appropriate follow up is provided to each member of the Native American community.”

The following lists the specific goals of Aim 3 In order to improve care transitions within the IHS hospitals:

  • 100% of Inpatient/Emergency Department discharge planning and follow up within 48 hours
  • 95% accuracy of ESI level and establishing education for front line staff
  • Emergency Department throughput time – arrival to departure 120 minutes or less

Lori Hestad, program manager for Great Plains QIN - SDLori Hestad, MBA, PATH program manager states, “As we continue to develop relationships with the service unit staff, we hope to continue to work as a team in order to meet the goals of this Aim.”

In order to sustain and monitor the work of this Aim, the service units have added the process improvement projects of care transitions to their monthly Quality Assurance Process Improvement (QAPI) meetings. Partnership and support from both the service units and Area Office has enabled PATH program managers to effectively communicate the goals of the Aim in order to ensure patients receive the best quality care at IHS facilities.