So What About Jack?

By Kindred Healthcare

NOTE: Jack's story is purely hypothetical and was crafted specifically for 2013 Clinical Impact Symposium attendees to use as an exercise in care transitions. Any resemblance to a person living or deceased is coincidental.

 (l-r) Matt Sivret, Tony Disser, Susan Sender, Kathy Owens, Mary Van de Kamp (l-r) Matt Sivret, Tony Disser, Susan Sender, Kathy Owens, Mary Van de Kamp

As the Fifth Annual Kindred Clinical Impact Symposium wraps up, participants came together to make some recommendations for further care of our fictitious patient, Jack, who has many co-morbid conditions and ended up in the post-acute care continuum after being hit by a car while riding his bike, requiring surgery for a broken femur.

After his initial discharge from the acute care hospital, Jack went to a skilled nursing facility, back to the acute care hospital, then to a transitional care hospital and ultimately he was transitioned to home health care. At the current moment, Jack’s home health providers are concerned about his agitated state and resistance to taking medications and exercising.

As Jack continues his journey in the post-acute continuum, CIS participants had some common recommendations for his care:

  • It’s all about the patient. At the end of the day, Jack is the most important part of his care team. Ask Jack – patient treatment determination is still a patient right.
  • Care coordination across settings is paramount.
  • Medication reconciliation is important.
  • Improve communication and IDT (Interdisciplinary Team) participation – reach out to colleagues across the continuum. Better communication between settings is critical, and can be as simple as picking up the phone.
  • Patient and family education can lead to better outcomes, as their role and buy-in in caring for the patient is crucial.

Later today, CIS participants will disperse back to their respective facilities – all across the country – with Jack fresh in their minds, remembering his story and those recommendations as they care for patients like Jack, facilitating the best outcomes possible across the entire continuum of care.

Said Mary Van de Kamp, Senior Vice President, Quality and Integrated Care for Kindred Healthcare, as she encouraged participants to take Jack’s lessons home with them: “There are lots of Jacks and if we make a difference with just one of them, we’ve made a huge impact.”

(l-r) Matt Sivret, Tony Disser, Susan Sender, Kathy Owens, Mary Van de Kamp