Transitional Care & Pressure Ulcers Project Toolkit

In 2007, the Oregon IHI Network and the Oregon leadership of the Advancing Excellence in America’s Nursing Homes campaign formed a Joint Committee to plan and develop cross-setting interventions for transitional care, with an initial focus on pressure ulcers. The Joint Committee convened an Advisory Panel of clinicians, educators, health plan representatives, and experts from regulatory and quality improvement agencies to

• identify best practices for preventing or minimizing pressure ulcers in hospitals, nursing homes, community-based long-term care, and home health agencies
• develop a handoff data set of pressure ulcer-related information that would accompany patients in transition from one setting to another

These tools, with support materials such as the Braden Scale for predicting pressure ulcer risk, were compiled in a toolkit and then pilot-tested in multiple care settings in four communities. The Joint Committee and its constituent organizations have endorsed the toolkit materials as support for efforts to improve pressure ulcer prevention and care in Oregon.

Downloadable toolkit materials

Table of contents
Introduction

Convening an Advisory Panel

Introduction
Questions for the Advisory Panel
Findings of the Advisory Panel

Provider Tools

Introduction

Oregon Best Practices

Hospitals
Best Practices
Audit/Checklist

Nursing homes
Best Practices
Audit/Checklist

Community-based care
Best Practices
Audit/Checklist

Home health & hospice
Best Practices
Audit/Checklist

Other tools
Braden Scale for Predicting Pressure Sore Risk
Pressure Ulcer Definition and Stages
Summary of Pressure Ulcer Assessment Variables
Clinical Signs and Symptoms for Infection
Nutritional Care Guidelines
Pocket card: positioning, pressure points
Recommended Interventions to Prevent or Minimize Pressure Ulcers

Handoff dataset

Introduction
The core version

Pilot versions
Albany
Astoria
Eugene
The Dalles

Body diagrams
Handoff dataset audit

Community Tools

Introduction—Community implementation strategy

Building a team (around a safe table)

Overview
Work plan
Participation agreement
Confidentiality agreement

Completing a gap analysis (best practices audit/checklist)

Overview

Doing a case review

Overview
Case review outline
Case review ideas

Measuring prevalence (baseline and remeasurement)

Overview
Prevalence worksheet

Running a pilot

Overview
Handoff dataset pilot steps
Handoff dataset pilot process
Handoff dataset audit

Implementing within a community

Overview
Sample agenda for education day
Sample community policy and procedure

 

For more information about these materials, contact Stacy Moritz, Director of Medicare Quality Services, at 503-382-3918 or smoritz@acumentra.org.

Joint Committee members

Acumentra Health
Oregon Alliance of Senior and Health Services
Oregon Association for Home Care
Oregon Association of Hospitals and Health Systems
Oregon Health Care Association
Oregon Patient Safety Commission
Seniors and People with Disabilities