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Health professionals helping patients transition safely

The Safe Transitions group includes (front from left) Shawn Christianson, Katie Nordick, Jody Malone, Tina Jenson, William Henke; back row TJane VonRuden, Deb Steffl, Kandi Adkins, Lynnell Simonson Popowski, Laura Seleen, Deborah Leedahl, Angie Olson, Cheryl Krause, Missy Klemin, Ann Leonard. DL NEWSPAPERS/Pippi Mayfield

In a short period of time, a patient could go from seeing a doctor at the clinic to being admitted to the hospital and under a different doctor’s care, to short term care after being released from the hospital and under yet another doctor’s care to back home with their family physician.

That’s a lot of doctors, a lot of information and a lot of confusion ­— for patients and their providers.

So a group of healthcare related professionals have formed the Safe Transitions group, working to make just that — safe transitions for patients.

Laura Seleen, director of nursing at Essentia Health Oak Crossing, said discussions of forming a group started about a year and a half ago, “talking about readmissions into the hospital.”

They started by making a plan to reduce hospital readmissions, which was a part of a nationwide program called Project RED (Project Re-Engineered Discharge). The group even won an award through the Minnesota Hospital Association for their work on Project RED.

With their project, Essentia Health St. Mary’s patients spent 70 fewer nights in the hospital last year.

With that success in place, the group evaluated what their next step was. They have taken to tackling other concerns — like the sharing of information between doctors that will benefit the patient. But with data privacy laws, that can also be a challenge.

“It was apparent to us it was transition of care,” Seleen said.

Another step was to make sure that with all doctors and health professional involved with the patient, “each party has access to records,” she said.

That doesn’t mean within the same health care institution either, but between them, like Essentia Health and Sanford, for example. This also involves everyone from pharmacies to nursing homes.

Though some providers are on the new Epic Care Link system, not all are, so records can be a problem to access at times.

While it’s beneficial for everyone to be on the same page, it’s also a good thing to have various entities working together because each brings a different idea that could work for everyone.

“We talk about how each side could do things better,” Essentia Health Quality Director Shawn Christianson said.

Once the information sharing issue has a solution in place, the group will continue meeting to find resolves for better ways to work with nursing home capabilities, medication reconciliation, anti-aging services and more.

“As long as we can improve,” Seleen said, they will be meeting.

For now though, they are concentrating on a seamless transition of care for their patients with “no interruptions in care,” she said.

Follow Pippi Mayfield on Twitter at @PippiMayfield.