About
This lecture will focus on understanding and improving the family experience of discharge. We are eager to foster a productive conversation about current efforts to engage families in planning for discharge, common sense practices that facilitate dialogue between families and clinicians, and pragmatic steps that hospitals and clinicians can take to improve the discharge experience for families. To highlight just a few exciting new initiatives across the country aimed at improving family and patient engagement throughout the discharge process, we have invited panelists specializing in family-centered advocacy, including representatives from Family Voices of California (FVCA) and Boston Children’s Hospital’s Teen Advisory Committee (TAC).
Presenters | Allison Gray, Elana Ford, Annette Lysan, and Linda Delahunty
Allison Gray (FVCA)
Ms. Gray became the Family Voices of California (FVCA) Project Leadership State Liaison in April 2013. She has a background in education and educational publishing and came to this work after years of frustration navigating systems and services for her son with special health care needs. She is the California Family Advocate on the Western States Genetics Services Collaborative.
Elana Ford (FVCA)
Ms. Ford graduated from FVCA Project Leadership in November 2014. She is the parent of two children with disabilities/special health care needs and has a passion for improving the systems and services that serve all children with special needs. She currently serves on the University of San Francisco Family Advisory Committee, acts as the co-administrator of a support group for Bay Area special needs families, and is involved in advocacy around hospital administration (Patient Centered Care, Discharge Planning, Parent as Educator) and state level legislation to protect medically fragile children and children with disabilities.
About Family Voices of California and Project Leadership
Family Voices of California is a statewide collaborative of locally-based parent-run centers working to ensure high-quality health care for children and youth with special health care needs. FVCA provides information for both centers and families to advocate for improved public and private policies, builds partnerships between professionals and families, and serves as a vital resource on health care. Project Leadership is a comprehensive training series offered by FVCA that includes a seven-session training curriculum plus mentorship, information, supports, and linkages with FVCA’s statewide network. The project is designed to help family members develop the skills and tools they need to partner at all levels of decision making and engage in public policy advocacy activities in California on behalf of children/youth with special healthcare needs. The goal of Project Leadership is to increase the number of family members and caregivers of children/youth with special healthcare needs who are prepared and supported to become advocates for health care policy and service improvements.
Annette Lysan (TAC)
Ms. Lysan is a 21 year-old psychology major at Bridgewater State University and is studying to be a child life specialist. She has served on TAC since her sophomore year of high school and is approaching her 6th year on the committee. She initially joined TAC to become more involved with the hospital and help make the hospital experience better for teens. Her interests and hobbies include skiing, arts and crafts, and hanging out with her friends.
About Boston Children's Hospital's Teen Advisory Committee
TAC is comprised of 26 adolescents and young adults age 14 to 22 years who receive their care at Boston Children’s Hospital. The committee serves as a forum for discussing and promoting recommendations and suggestions to enhance the quality and quantity of programs and practices that affect teen patients. Committee members are regularly involved in the development, administration, and execution of quality improvement projects, focus groups, and publicity campaigns, all of which are done voluntarily. Perhaps most importantly, the committee provides teens with valuable leadership experience, public speaking and presentation opportunities, and the skills necessary for self-advocacy in their own health care journey.
This lecture will focus on understanding and improving the family experience of discharge. We are eager to foster a productive conversation about current efforts to engage families in planning for discharge, common sense practices that facilitate dialogue between families and clinicians, and pragmatic steps that hospitals and clinicians can take to improve the discharge experience for families. To highlight just a few exciting new initiatives across the country aimed at improving family and patient engagement throughout the discharge process, we have invited panelists specializing in family-centered advocacy, including representatives from Family Voices of California (FVCA) and Boston Children’s Hospital’s Teen Advisory Committee (TAC).
Presenters | Allison Gray, Elana Ford, Annette Lysan, and Linda Delahunty
Allison Gray (FVCA)
Ms. Gray became the Family Voices of California (FVCA) Project Leadership State Liaison in April 2013. She has a background in education and educational publishing and came to this work after years of frustration navigating systems and services for her son with special health care needs. She is the California Family Advocate on the Western States Genetics Services Collaborative.
Elana Ford (FVCA)
Ms. Ford graduated from FVCA Project Leadership in November 2014. She is the parent of two children with disabilities/special health care needs and has a passion for improving the systems and services that serve all children with special needs. She currently serves on the University of San Francisco Family Advisory Committee, acts as the co-administrator of a support group for Bay Area special needs families, and is involved in advocacy around hospital administration (Patient Centered Care, Discharge Planning, Parent as Educator) and state level legislation to protect medically fragile children and children with disabilities.
About Family Voices of California and Project Leadership
Family Voices of California is a statewide collaborative of locally-based parent-run centers working to ensure high-quality health care for children and youth with special health care needs. FVCA provides information for both centers and families to advocate for improved public and private policies, builds partnerships between professionals and families, and serves as a vital resource on health care. Project Leadership is a comprehensive training series offered by FVCA that includes a seven-session training curriculum plus mentorship, information, supports, and linkages with FVCA’s statewide network. The project is designed to help family members develop the skills and tools they need to partner at all levels of decision making and engage in public policy advocacy activities in California on behalf of children/youth with special healthcare needs. The goal of Project Leadership is to increase the number of family members and caregivers of children/youth with special healthcare needs who are prepared and supported to become advocates for health care policy and service improvements.
Annette Lysan (TAC)
Ms. Lysan is a 21 year-old psychology major at Bridgewater State University and is studying to be a child life specialist. She has served on TAC since her sophomore year of high school and is approaching her 6th year on the committee. She initially joined TAC to become more involved with the hospital and help make the hospital experience better for teens. Her interests and hobbies include skiing, arts and crafts, and hanging out with her friends.
About Boston Children's Hospital's Teen Advisory Committee
TAC is comprised of 26 adolescents and young adults age 14 to 22 years who receive their care at Boston Children’s Hospital. The committee serves as a forum for discussing and promoting recommendations and suggestions to enhance the quality and quantity of programs and practices that affect teen patients. Committee members are regularly involved in the development, administration, and execution of quality improvement projects, focus groups, and publicity campaigns, all of which are done voluntarily. Perhaps most importantly, the committee provides teens with valuable leadership experience, public speaking and presentation opportunities, and the skills necessary for self-advocacy in their own health care journey.
Due to technical errors, the first 30 minutes of the webinar are not included in the recording. However, slide deck of the entire event can be found here.
About
This third lecture will will center on novel strategies and interventions that hospital staff can implement post-discharge to ensure a smooth transition away from the hospital. To demonstrate the practical application of such initiatives, we have invited two expert panelists to discuss exemplar approaches to post-discharge follow-up care occurring at each of their hospitals.
Presenters | Michael Steiner and Kelly Dunn
Michael Steiner, MD, MPH
Dr. Steiner is the Division Chief for General Pediatrics and Adolescent Medicine at the University of North Carolina and North Carolina Children’s Hospital. This division, which includes the Section of Hospital Pediatrics, cares for hospitalized children on the two inpatient general pediatrics service, coordinates transfers and admissions for all medical patients into the children’s hospital, and has a vibrant inpatient consultation service. Dr. Steiner’s recent research and programmatic interests have been focused on the care of children with medical complexity, including how families engage with specialty and primary care, operational systems for care transfers, and the role of social determinants of health for children with medical complexity.
Exemplar Approach to Post-discharge Follow-up
UNC’s Pediatric Hospital Transition Clinic seeks to improve care for children post-discharge by helping with care transitions and outpatient follow-up of complicated inpatients. The clinic employs a 3-part intervention:
Kelly Dunn, MS, RN, CPNP
Ms. Dunn has worked as a Pediatric Nurse Practitioner in inpatient General Pediatrics at Boston Children’s Hospital since 2009, spearheading the Early Discharge initiative to help patients and families prepare to return home. Ms. Dunn specializes in crafting clinical strategies aimed at improving systems issues while providing excellent clinical care and without losing sight of how we may address healthcare disparities.
Exemplar Approach to Post-discharge Follow-up
DisCo (short for Discharge Communication) is a digital communication tool that families access after hospital discharge via smartphone or email. DisCo utilizes a brief survey sent via text/email within 24 hours of discharge to encourage caregivers to communicate with a member of the inpatient medical team regarding concerns about prescriptions, primary care follow-up, or any other issue. Caregiver responses reporting concerns are then flagged in a web-based dashboard, prompting a pediatric nurse practitioner to follow up with the caregiver by phone to address their concerns and make recommendations about further care needs.
This third lecture will will center on novel strategies and interventions that hospital staff can implement post-discharge to ensure a smooth transition away from the hospital. To demonstrate the practical application of such initiatives, we have invited two expert panelists to discuss exemplar approaches to post-discharge follow-up care occurring at each of their hospitals.
Presenters | Michael Steiner and Kelly Dunn
Michael Steiner, MD, MPH
Dr. Steiner is the Division Chief for General Pediatrics and Adolescent Medicine at the University of North Carolina and North Carolina Children’s Hospital. This division, which includes the Section of Hospital Pediatrics, cares for hospitalized children on the two inpatient general pediatrics service, coordinates transfers and admissions for all medical patients into the children’s hospital, and has a vibrant inpatient consultation service. Dr. Steiner’s recent research and programmatic interests have been focused on the care of children with medical complexity, including how families engage with specialty and primary care, operational systems for care transfers, and the role of social determinants of health for children with medical complexity.
Exemplar Approach to Post-discharge Follow-up
UNC’s Pediatric Hospital Transition Clinic seeks to improve care for children post-discharge by helping with care transitions and outpatient follow-up of complicated inpatients. The clinic employs a 3-part intervention:
- During admission, patients are visited by the transition team and screened for social determinants of health
- Then, patients are followed up 3 days after discharge via a phone call or a clinic visit at UNC’s Diagnostic and Complex Care clinic
- Lastly, there is an active re-introduction to community-based care, often via the Child Health Accountable Care Collaborative (CHACC) electronic communication system, improving communication with the child’s PCP.
Kelly Dunn, MS, RN, CPNP
Ms. Dunn has worked as a Pediatric Nurse Practitioner in inpatient General Pediatrics at Boston Children’s Hospital since 2009, spearheading the Early Discharge initiative to help patients and families prepare to return home. Ms. Dunn specializes in crafting clinical strategies aimed at improving systems issues while providing excellent clinical care and without losing sight of how we may address healthcare disparities.
Exemplar Approach to Post-discharge Follow-up
DisCo (short for Discharge Communication) is a digital communication tool that families access after hospital discharge via smartphone or email. DisCo utilizes a brief survey sent via text/email within 24 hours of discharge to encourage caregivers to communicate with a member of the inpatient medical team regarding concerns about prescriptions, primary care follow-up, or any other issue. Caregiver responses reporting concerns are then flagged in a web-based dashboard, prompting a pediatric nurse practitioner to follow up with the caregiver by phone to address their concerns and make recommendations about further care needs.
About
This second lecture will focus on the Conditions of Participation for Discharge Planning set forth by the Centers for Medicare & Medicaid Services and their practical implications for providing discharge care for children with medical complexity in local healthcare settings. The lecture will feature an in-depth discussion with three panelists, each renowned for their expertise in nursing, case management, social work, and hospital administration.
Presenters | Jackie Birmingham, Shawna Grossman Kates, & Edward Woomer
Jackie Birmingham, MS, RN, CMAC
Ms. Birmingham is VP Emerita for Clinical Leadership at Curaspan Health Group, where she specializes in the application of federal and state rules and regulations as they apply to transition of patient care across the continuum, with an emphasis on compliance to Conditions of Participation for Discharge Planning (Transition Management). She has more than 25 years of experience in case management, directing discharge planning, and educating nurses and social workers involved in care transitions who work for providers and payers. She is an active member of the editorial board of Professional Case Management, was awarded the Case Management Society of America’s Case Manager of the Year Award in 2000, and has had significant subcommittee involvement at the American Case Management Association. Ms. Birmingham is also the author of several books and articles, most recently “Discharge Planning Guide: Tools for Compliance, 3rd Edition,” and "Patient Choice in Discharge Planning.”
Shawna Grossman Kates, MSW, LSW, MBA, CMAC
Ms. Kates currently serves as Director of Case Management and Bed Management for Community Medical Center/Barnabas Health and is a consulting associate for the Center for Case Management. She brings a deep knowledge of operations, strategic planning, case management, and social work from her numerous leadership positions in social work and case management organizations. Ms. Kates’ expertise is in the development of patient care delivery models, financial recovery, and case management programs, with a focus on enhancing and distinguishing the role of social work. She recently stepped down as the 2013-2014 President of the Society for Social Work Leadership in Health Care, where she has held leadership roles for 20 years. She is a member of the Case Management Administrators Certificate Advisory Board, the National Association of Professional Women, and the National Association of Social Workers.
Edward Woomer, LCSW
Mr. Woomer has over 30 years of experience in social work and is currently an administrator at Alfred I. DuPont Hospital for Children, overseeing 18 different departments and providing leadership to initiatives focused on improving the patient experience. He has a wealth of knowledge and experience related to executing social work programs and has worked extensively to advocate for the rights of children and families in healthcare settings. Mr. Woomer is past president of the Society for Social Work Leadership in Health Care (2012-13), served on the Commonwealth Fund Task Force to develop a national model of pediatric care coordination, and was chair of the Gestalt Therapy Institute of Philadelphia. Most recently, he received the 2015 Ida M. Cannon Award, the most prestigious award presented by the Society for Social Work Leadership in Health Care.
This second lecture will focus on the Conditions of Participation for Discharge Planning set forth by the Centers for Medicare & Medicaid Services and their practical implications for providing discharge care for children with medical complexity in local healthcare settings. The lecture will feature an in-depth discussion with three panelists, each renowned for their expertise in nursing, case management, social work, and hospital administration.
Presenters | Jackie Birmingham, Shawna Grossman Kates, & Edward Woomer
Jackie Birmingham, MS, RN, CMAC
Ms. Birmingham is VP Emerita for Clinical Leadership at Curaspan Health Group, where she specializes in the application of federal and state rules and regulations as they apply to transition of patient care across the continuum, with an emphasis on compliance to Conditions of Participation for Discharge Planning (Transition Management). She has more than 25 years of experience in case management, directing discharge planning, and educating nurses and social workers involved in care transitions who work for providers and payers. She is an active member of the editorial board of Professional Case Management, was awarded the Case Management Society of America’s Case Manager of the Year Award in 2000, and has had significant subcommittee involvement at the American Case Management Association. Ms. Birmingham is also the author of several books and articles, most recently “Discharge Planning Guide: Tools for Compliance, 3rd Edition,” and "Patient Choice in Discharge Planning.”
Shawna Grossman Kates, MSW, LSW, MBA, CMAC
Ms. Kates currently serves as Director of Case Management and Bed Management for Community Medical Center/Barnabas Health and is a consulting associate for the Center for Case Management. She brings a deep knowledge of operations, strategic planning, case management, and social work from her numerous leadership positions in social work and case management organizations. Ms. Kates’ expertise is in the development of patient care delivery models, financial recovery, and case management programs, with a focus on enhancing and distinguishing the role of social work. She recently stepped down as the 2013-2014 President of the Society for Social Work Leadership in Health Care, where she has held leadership roles for 20 years. She is a member of the Case Management Administrators Certificate Advisory Board, the National Association of Professional Women, and the National Association of Social Workers.
Edward Woomer, LCSW
Mr. Woomer has over 30 years of experience in social work and is currently an administrator at Alfred I. DuPont Hospital for Children, overseeing 18 different departments and providing leadership to initiatives focused on improving the patient experience. He has a wealth of knowledge and experience related to executing social work programs and has worked extensively to advocate for the rights of children and families in healthcare settings. Mr. Woomer is past president of the Society for Social Work Leadership in Health Care (2012-13), served on the Commonwealth Fund Task Force to develop a national model of pediatric care coordination, and was chair of the Gestalt Therapy Institute of Philadelphia. Most recently, he received the 2015 Ida M. Cannon Award, the most prestigious award presented by the Society for Social Work Leadership in Health Care.
About
This first lecture will focus on Dr. Marianne Weiss and her team’s research with parents of hospitalized children that has led to the development and refinement of the Pediatric version of the Readiness for Hospital Discharge Scale that can be used as an outcome metric of hospitalization and a tool to assist identification of children at risk for readmission.. Included will be a discussion of discharge preparation factors that contribute to readiness for pediatric discharge, parent and provider perspectives on discharge readiness, and implications for pediatric practice and research.
Presenter | Marianne Weiss, DNSc, RN
Dr. Weiss is Associate Professor and Wheaton Franciscan – St Joseph / Sister Rosalie Klein Professor of Women’s Health at Marquette University College of Nursing in Milwaukee, Wisconsin. She holds a Bachelor of Science in Nursing degree from McGill University in Montreal, Canada, and Master of Science in Nursing and Doctor of Nursing Science degrees from the University of San Diego. Her program of research focuses on discharge preparation, assessment of discharge readiness, and post-discharge outcomes across the range of patients discharged from acute care hospitals. This work has included development of instruments to measure care processes and patient outcomes across the transition in care from hospital to home. These instruments include the Quality of Discharge Teaching Scale, the Readiness for Hospital Discharge Scale, and the Post-Discharge Coping Difficulty Scale, with testing completed in adult medical-surgical patients, postpartum mothers, and parents of hospitalized children. Recently she has completed a study with parents of hospitalized children that documents the trajectory of influence of discharge preparation to readiness for discharge to post-discharge coping difficulty and readmissions. Dr Weiss is the Principal Investigator for the READI study, a multi-site study of implementation of discharge readiness assessment as a standard nursing practice for hospital discharge.
This first lecture will focus on Dr. Marianne Weiss and her team’s research with parents of hospitalized children that has led to the development and refinement of the Pediatric version of the Readiness for Hospital Discharge Scale that can be used as an outcome metric of hospitalization and a tool to assist identification of children at risk for readmission.. Included will be a discussion of discharge preparation factors that contribute to readiness for pediatric discharge, parent and provider perspectives on discharge readiness, and implications for pediatric practice and research.
Presenter | Marianne Weiss, DNSc, RN
Dr. Weiss is Associate Professor and Wheaton Franciscan – St Joseph / Sister Rosalie Klein Professor of Women’s Health at Marquette University College of Nursing in Milwaukee, Wisconsin. She holds a Bachelor of Science in Nursing degree from McGill University in Montreal, Canada, and Master of Science in Nursing and Doctor of Nursing Science degrees from the University of San Diego. Her program of research focuses on discharge preparation, assessment of discharge readiness, and post-discharge outcomes across the range of patients discharged from acute care hospitals. This work has included development of instruments to measure care processes and patient outcomes across the transition in care from hospital to home. These instruments include the Quality of Discharge Teaching Scale, the Readiness for Hospital Discharge Scale, and the Post-Discharge Coping Difficulty Scale, with testing completed in adult medical-surgical patients, postpartum mothers, and parents of hospitalized children. Recently she has completed a study with parents of hospitalized children that documents the trajectory of influence of discharge preparation to readiness for discharge to post-discharge coping difficulty and readmissions. Dr Weiss is the Principal Investigator for the READI study, a multi-site study of implementation of discharge readiness assessment as a standard nursing practice for hospital discharge.
