Transition of Care Business Model Development

Transition of Care Business Model Development

Role: Inpatient Patient Transition Coordinator

The goal of this initiative was to enhance the transition of care process by integrating home health services more deeply into the broader Care Management framework. This required reimagining how Case Management and social work teams handled home care and ensuring these teams were effectively collaborating to provide continuous, high-quality care. Key steps taken included:

Key Steps Taken:

• Analysis of Team Structure & Roles: I started by assessing the percentage of home care managed by Case Management and the transitional care teams. This analysis helped identify any gaps in the current team structure and how the home care teams could be better integrated into the overall care management model.

• Monitoring Referrals & Acceptance Rates: I tracked referral volumes and acceptance rates, comparing Case Management versus the transitional care team's handling of home-bound patient needs. This data provided insight into how efficiently patients were being referred and whether the right resources were being utilized.

• Developing New Workflows: A crucial step was creating a more seamless workflow that allowed consults between the two teams. This ensured that the transition team was involved in the care coordination process from start to finish, resulting in faster, more coordinated care for patients.

• Creating a Conversation Guide for Interdisciplinary Rounds: I worked to establish a structured guide to facilitate discussions during interdisciplinary rounds. This guide ensured that all team members had clear, actionable points to address, reducing miscommunication and enhancing the decision-making process.

• Employee Salary Gap Analysis & Workload Distribution: Recognizing the need for a balanced workforce, I assisted in conducting a salary gap analysis and a reporting system to evaluate the workload per full-time equivalent (FTE). This analysis helped identify any potential resource shortages and made a case for additional staffing, if necessary.

• Transitioning to the Network: As part of this initiative, I also assisted with developing a transition plan for home health to be fully integrated into the health system's network, including identifying hardware needs and resource allocation.

Impact:

• Improved Integration: Enhanced collaboration between Case Management and transitional care teams, leading to a more cohesive care delivery process.

• Increased Efficiency: Streamlined workflows reduced delays in patient transitions and ensured better care coordination across teams.

• Optimized Resources: The salary gap analysis and workload evaluation led to more efficient staffing and resource allocation, which improved overall team performance.

• Leadership Growth: This initiative directly contributed to my promotion to Manager of the Transitional Care Team, showcasing my leadership and problem-solving abilities.

• Scalability: The new business model served as a scalable framework for improving other cross-functional workflows within the organization.

• Directly lead to my promotion to manager of Transition of Care.