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Care planning across the continuum of care

  • 1.  Care planning across the continuum of care

    Posted 09-16-2015 16:09

    We are interested in the different methods various sites with different EMRs use in care planning across the continuum of care from pre-hospital/MD office to the hospital and post discharge to home / hospice / SNF / LTF. Are 3rd party applications like ProVation or Elsevier utilized and what is the outcome?

    Thanks for any thoughts and experience shared.

    Ken Barnes RN
    Clinical Informatics Nurse

    Scripps Health
    San Diego

  • 2.  RE: Care planning across the continuum of care

    Posted 09-18-2015 17:13

    Hi all,

    I am just starting the build for our "Longitudinal Plan of Care" for RCHSD's ACO pilot project so I am just learning and am interested in other's experiences as well. 





    Kathy Klimpel, MSN, RN, CNS, RN-BC

    Sr Clinical Informaticist

    Rady Children's Hospital-San Diego

    MC 5083

    3020 Children's Way

    San Diego, CA 92123

    858-966-7864 (office)

    858-493-6798 (pager)


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  • 3.  RE: Care planning across the continuum of care

    Posted 09-19-2015 10:20
    Hi Ken,

    For the past 3 1/2 years I have been employed as an EHR clinical analyst for implementation of Epic at the Sutter Healthcare sites in Sacramento and San Francisco areas. 

    Sutter utilizes Elsevier for discharge instructions, as their ambulatory, ED, and inpatient units. 
    This allows for standardization of instructions, across the enterprise. 

    One great feature is the ability of the RN or other clinician to "preview" the instructions, prior to attachment to the record and printing.
    In other words, the instructions for wound care are available in a simple or more complex option, diagrams or not.
    The text can be printed as is, or modified through its functionality as a word-type document.
    A variety of languages can be utilized, also.

    The instructions can be accessed at any time during the hospitalization, for real-time teaching, or of course, at discharge. 
    By attachment to the discharge instructions, there is electronic capture they were provided. 

    Sutter has had the Elsevier reps come to the sites, within about 30 days after go-live, to walk the units and assist the RNs with the functionality if needed. I have also seen in-services and "drop-ins", in other words, whatever support the site believes is needed, the Elsevier folks have been most accommodating. 

    Hope this is helpful, let me know if you need any other information.

    Nancy Gosnell (formerly Gardner)
    Carlsbad, CA