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Allina Hospitals and Clinics
    Aftercare Proposal




     Jamie Otto / Mike Borell / Emily Keenan
Start of
           Aftercare


The end for doctors and nurses but
  the beginning for patients and
             families.




         Jamie Otto / Mike Borell / Emily Keenan
Allina Mission Statement
       Our Mission
       We serve our communities by providing exceptional care, as we
       prevent illness, restore health and provide comfort
       to all who entrust us with their care.


       Our Vision
       We will:
         put the patient rst;
         make a di erence in people’s lives by providing exceptional
         care and service;
         create a healing environment where passionate people thrive
         and excel; and
         lead collaborative e orts that solve our community’s health
         care challenges.


       Our Values
       INTEGRITY        We match our actions with our words.
       RESPECT      We treat everyone with honor, dignity
                    and courtesy.
       TRUST       We act in the best interests of our patients, physicians,
                   communities and one another.
       COMPASSION          We create a caring environment for our
                           patients and one another.
       STEWARDSHIP          We use our resources wisely.




      Jamie Otto / Mike Borell / Emily Keenan
Project Purpose Statement
• To explore the information provided to
patients before starting at-home recovery.

• In order to empower the patient, connect
them to caregivers, and make them more
independent and goal-driven in their
aftercare.

• So that Allina can facilitate and encourage
their patients’ aftercare habits and increase
their quality service ratings.

              Jamie Otto / Mike Borell / Emily Keenan
Current Practices
• Sit down before discharge

• Bulky Packets

• Check-in Calls

• Check-in Visits

• Care Guides


                Jamie Otto / Mike Borell / Emily Keenan
Case Studies
Judy
Gender: Female
Age: late 50s
Connection: Mother to a child
who had a heart transplant
and has been a patient herself
What worked in the past?
The personal connection between doctors, extended stay patient, and nurses has been great
for her. It became a real community dedicated to the wellbeing of her daughter. She and
her daughter used MyChart to show the multiple doctors they were in contact with what
medications the other practitioners had her daughter on and keep everything in one place.

What would Judy like to see in aftercare?
The family should be included if they will have a large part in the patient’s care, and patients
who aren’t frequent hospital visitors should know what questions to ask.

What would Judy like to see inside of the hospital?
There should be room for family to go and visitors to stay inside of the rooms. There should
also be information about how to take charge of your own care.

How was the communication with the care team?
Fantastic, because she took the initiative and learned how to ask the right questions. After
spending so much time in medical facilities, she has learned how they function and how to
navigate them.

What were some obstacles in aftercare Judy has experienced?
Sometimes, working with a hospice nurse is necessary and other times it is not. She has
experienced both good and bad ones. Also, there needs to be support for people getting out
of surgery since, while she and her daughter did, some people do not have that.

How much access should family or support networks be given?
If it is a child, the parents or guardian should have total access. Otherwise, the patient
should be able to hand pick what information people are given.

Other Comments:
She believes that a patient needs to advocate for themselves and learning how to do that is
really how someone successfully takes charge of their own care.




         Jamie Otto / Mike Borell / Emily Keenan
Judy




“It was a stressful situation during release and it was hard to
             remember what the doctor said later.”



               Jamie Otto / Mike Borell / Emily Keenan
Budd




"In the case of the elderly or those patients that cannot properly
  take care of themselves, their support networks should be the
 focus of the aftercare instruction. Either that, or the family and
    loved ones should speci cally have a place to go with their
                             questions."
                 Jamie Otto / Mike Borell / Emily Keenan
Dawn




"They are counting on the people to be independent."



           Jamie Otto / Mike Borell / Emily Keenan
Caleb




“If someone is not pushing you to do your physical therapy, it’s impossible to do.”

  “There’s things we don’t understand as patients, but doctors need to know.”


                          Jamie Otto / Mike Borell / Emily Keenan
Insights
• Information
• Emotional Aspects
• Disconnect
• Patient Driven
• Dependence
• Family




             Jamie Otto / Mike Borell / Emily Keenan
Current Proposal
The Aftercare Counselor
Changes to Online Care



     Jamie Otto / Mike Borrell / Emily Keenan
The Aftercare Counselor




      Jamie Otto / Mike Borell / Emily Keenan
The Aftercare Counselor
•Medical Professional/Counselor/Friend
•Bridge between home and hospital
•From pre-release to end of aftercare




             Jamie Otto / Mike Borell / Emily Keenan
The Aftercare Counselor
•Answers questions to avoid the
revolving door hospital

•Keeps patients accountable for their
health

•Position can be      lled by medical students,

psychology students, social work students,

and retired doctors and nurses.
             Jamie Otto / Mike Borell / Emily Keenan
What others do




  Jamie Otto / Mike Borell / Emily Keenan
Changes to Online Care

CONGRATULATIONS!                                YOUR WEEKLY PROGRESS:

                                          50
                                                                         Time(mins)
                                         40                              Miles

                                         30

                                         20

                                          10

                                          0

                                                    Time Vs Miles Ran
 You’ve reached your weekly
 fitness goal! Celebrate with a
   Fruit and Yogurt Parfait.              30
                                                                        This week
                                          25                            Last Week
                                          20
  Because you performed at
                                           15
 least 15 minutes of Cardio 5
                                          10
days this week, you’ve reduced
                                           5
 your risk of heart disease by
                                           0
              25%.                                     Miles Ran




                    Jamie Otto / Mike Borell / Emily Keenan
Future Proposal
The Aftercare Community




     Jamie Otto / Mike Borrell / Emily Keenan
Technological Care
 Wireless heart monitors and
pedometers, connected to online
database


 Ability to track progress on your
smartphone or personal computer


 Retain phone services for those
without Internet access
           Jamie Otto / Mike Borrell / Emily Keenan
Structure of the
Aftercare Community
                  CARE GUIDE




SUPPORT   SUPPORT        SUPPORT           SUPPORT     SUPPORT
NETWORK   NETWORK        NETWORK           NETWORK     NETWORK




            Jamie Otto / Mike Borrell / Emily Keenan
Structure of the
Aftercare Community
                  CARE GUIDE




SUPPORT   SUPPORT        SUPPORT           SUPPORT     SUPPORT
NETWORK   NETWORK        NETWORK           NETWORK     NETWORK




            Jamie Otto / Mike Borrell / Emily Keenan
Structure of the
Aftercare Community
                  CARE GUIDE




SUPPORT   SUPPORT        SUPPORT           SUPPORT     SUPPORT
NETWORK   NETWORK        NETWORK           NETWORK     NETWORK




            Jamie Otto / Mike Borrell / Emily Keenan
Structure of the
Aftercare Community
                  CARE GUIDE




SUPPORT   SUPPORT        SUPPORT           SUPPORT     SUPPORT
NETWORK   NETWORK        NETWORK           NETWORK     NETWORK




            Jamie Otto / Mike Borrell / Emily Keenan
Services of an
Aftercare Community
 Home consultations

  Group meetings with other locals in
recovery

 Advanced technological care

 Personalized support connected to
your own existing community, support
network, and home caregivers

         Jamie Otto / Mike Borrell / Emily Keenan
Services in the Home

 Conversations about recovery

 Check-ups with your counselor

 Phone calls and online care

   In-home cooking lessons with a
licensed dietitian or nutritionist




          Jamie Otto / Mike Borrell / Emily Keenan
Connections with
   Local Area




   Jamie Otto / Mike Borrell / Emily Keenan
Connections with
   Local Area




   Jamie Otto / Mike Borrell / Emily Keenan
SUPPORT
                                                       NETWORKS




C
    CARE
    GUIDE




            Jamie Otto / Mike Borrell / Emily Keenan
SUPPORT
                                                       NETWORKS




C
    CARE
    GUIDE




            Jamie Otto / Mike Borrell / Emily Keenan
We welcome your
comments and feedback



      Jamie Otto / Mike Borell / Emily Keenan

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Allina Hospitals and Clinics Aftercare Proposal

  • 1. Allina Hospitals and Clinics Aftercare Proposal Jamie Otto / Mike Borell / Emily Keenan
  • 2. Start of Aftercare The end for doctors and nurses but the beginning for patients and families. Jamie Otto / Mike Borell / Emily Keenan
  • 3. Allina Mission Statement Our Mission We serve our communities by providing exceptional care, as we prevent illness, restore health and provide comfort to all who entrust us with their care. Our Vision We will: put the patient rst; make a di erence in people’s lives by providing exceptional care and service; create a healing environment where passionate people thrive and excel; and lead collaborative e orts that solve our community’s health care challenges. Our Values INTEGRITY We match our actions with our words. RESPECT We treat everyone with honor, dignity and courtesy. TRUST We act in the best interests of our patients, physicians, communities and one another. COMPASSION We create a caring environment for our patients and one another. STEWARDSHIP We use our resources wisely. Jamie Otto / Mike Borell / Emily Keenan
  • 4. Project Purpose Statement • To explore the information provided to patients before starting at-home recovery. • In order to empower the patient, connect them to caregivers, and make them more independent and goal-driven in their aftercare. • So that Allina can facilitate and encourage their patients’ aftercare habits and increase their quality service ratings. Jamie Otto / Mike Borell / Emily Keenan
  • 5. Current Practices • Sit down before discharge • Bulky Packets • Check-in Calls • Check-in Visits • Care Guides Jamie Otto / Mike Borell / Emily Keenan
  • 6. Case Studies Judy Gender: Female Age: late 50s Connection: Mother to a child who had a heart transplant and has been a patient herself What worked in the past? The personal connection between doctors, extended stay patient, and nurses has been great for her. It became a real community dedicated to the wellbeing of her daughter. She and her daughter used MyChart to show the multiple doctors they were in contact with what medications the other practitioners had her daughter on and keep everything in one place. What would Judy like to see in aftercare? The family should be included if they will have a large part in the patient’s care, and patients who aren’t frequent hospital visitors should know what questions to ask. What would Judy like to see inside of the hospital? There should be room for family to go and visitors to stay inside of the rooms. There should also be information about how to take charge of your own care. How was the communication with the care team? Fantastic, because she took the initiative and learned how to ask the right questions. After spending so much time in medical facilities, she has learned how they function and how to navigate them. What were some obstacles in aftercare Judy has experienced? Sometimes, working with a hospice nurse is necessary and other times it is not. She has experienced both good and bad ones. Also, there needs to be support for people getting out of surgery since, while she and her daughter did, some people do not have that. How much access should family or support networks be given? If it is a child, the parents or guardian should have total access. Otherwise, the patient should be able to hand pick what information people are given. Other Comments: She believes that a patient needs to advocate for themselves and learning how to do that is really how someone successfully takes charge of their own care. Jamie Otto / Mike Borell / Emily Keenan
  • 7. Judy “It was a stressful situation during release and it was hard to remember what the doctor said later.” Jamie Otto / Mike Borell / Emily Keenan
  • 8. Budd "In the case of the elderly or those patients that cannot properly take care of themselves, their support networks should be the focus of the aftercare instruction. Either that, or the family and loved ones should speci cally have a place to go with their questions." Jamie Otto / Mike Borell / Emily Keenan
  • 9. Dawn "They are counting on the people to be independent." Jamie Otto / Mike Borell / Emily Keenan
  • 10. Caleb “If someone is not pushing you to do your physical therapy, it’s impossible to do.” “There’s things we don’t understand as patients, but doctors need to know.” Jamie Otto / Mike Borell / Emily Keenan
  • 11. Insights • Information • Emotional Aspects • Disconnect • Patient Driven • Dependence • Family Jamie Otto / Mike Borell / Emily Keenan
  • 12. Current Proposal The Aftercare Counselor Changes to Online Care Jamie Otto / Mike Borrell / Emily Keenan
  • 13. The Aftercare Counselor Jamie Otto / Mike Borell / Emily Keenan
  • 14. The Aftercare Counselor •Medical Professional/Counselor/Friend •Bridge between home and hospital •From pre-release to end of aftercare Jamie Otto / Mike Borell / Emily Keenan
  • 15. The Aftercare Counselor •Answers questions to avoid the revolving door hospital •Keeps patients accountable for their health •Position can be lled by medical students, psychology students, social work students, and retired doctors and nurses. Jamie Otto / Mike Borell / Emily Keenan
  • 16. What others do Jamie Otto / Mike Borell / Emily Keenan
  • 17. Changes to Online Care CONGRATULATIONS! YOUR WEEKLY PROGRESS: 50 Time(mins) 40 Miles 30 20 10 0 Time Vs Miles Ran You’ve reached your weekly fitness goal! Celebrate with a Fruit and Yogurt Parfait. 30 This week 25 Last Week 20 Because you performed at 15 least 15 minutes of Cardio 5 10 days this week, you’ve reduced 5 your risk of heart disease by 0 25%. Miles Ran Jamie Otto / Mike Borell / Emily Keenan
  • 18. Future Proposal The Aftercare Community Jamie Otto / Mike Borrell / Emily Keenan
  • 19. Technological Care Wireless heart monitors and pedometers, connected to online database Ability to track progress on your smartphone or personal computer Retain phone services for those without Internet access Jamie Otto / Mike Borrell / Emily Keenan
  • 20. Structure of the Aftercare Community CARE GUIDE SUPPORT SUPPORT SUPPORT SUPPORT SUPPORT NETWORK NETWORK NETWORK NETWORK NETWORK Jamie Otto / Mike Borrell / Emily Keenan
  • 21. Structure of the Aftercare Community CARE GUIDE SUPPORT SUPPORT SUPPORT SUPPORT SUPPORT NETWORK NETWORK NETWORK NETWORK NETWORK Jamie Otto / Mike Borrell / Emily Keenan
  • 22. Structure of the Aftercare Community CARE GUIDE SUPPORT SUPPORT SUPPORT SUPPORT SUPPORT NETWORK NETWORK NETWORK NETWORK NETWORK Jamie Otto / Mike Borrell / Emily Keenan
  • 23. Structure of the Aftercare Community CARE GUIDE SUPPORT SUPPORT SUPPORT SUPPORT SUPPORT NETWORK NETWORK NETWORK NETWORK NETWORK Jamie Otto / Mike Borrell / Emily Keenan
  • 24. Services of an Aftercare Community Home consultations Group meetings with other locals in recovery Advanced technological care Personalized support connected to your own existing community, support network, and home caregivers Jamie Otto / Mike Borrell / Emily Keenan
  • 25. Services in the Home Conversations about recovery Check-ups with your counselor Phone calls and online care In-home cooking lessons with a licensed dietitian or nutritionist Jamie Otto / Mike Borrell / Emily Keenan
  • 26. Connections with Local Area Jamie Otto / Mike Borrell / Emily Keenan
  • 27. Connections with Local Area Jamie Otto / Mike Borrell / Emily Keenan
  • 28. SUPPORT NETWORKS C CARE GUIDE Jamie Otto / Mike Borrell / Emily Keenan
  • 29. SUPPORT NETWORKS C CARE GUIDE Jamie Otto / Mike Borrell / Emily Keenan
  • 30. We welcome your comments and feedback Jamie Otto / Mike Borell / Emily Keenan