Treating Clinician Videos

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Diagnosis

• Talk about the BIG PICTURE to the family
• Identify INTERDISCIPLINARY LEADERS – CONTINUITY ROLE
• Identify a CONTINUITY TEAM/ ATTENDING
• Prepare families as a COORDINATOR of their child’s care
• Mention possibility of TEAM RELATIONSHIP GAPS
• Offer CONTINUITY FAMILY MEETINGS
• Bring DISCHARGE up early

Intrahospital Transfer

• Prepare family for POTENTIAL TRANSFER; organize a UNIT TOUR; and talk about differences in UNIT ROUTINES
• Anticipate FAMILY STRESS over changes; provide RESOURCES to families
• TEAM HANDOFFS to include: BIG PICTURE INFORMATION; established COMMUNCATION ROUTINES with the family; FAMILY as a RESOURCE; BARRIERS FOR DISCHARGE
• Update CASE MANAGERS about home needs
• Expect MULTIPLE CONVERSATIONS

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Discharge

• Prepare families for changing ROUTINES
• SYNTHESIZE major issues, current management, discharge planning, care goals, and family updates
• Help families to become an ADVOCATE of their child: Encourage the use of a BINDER; they will become CENTRAL to clinical COMMUNICATION.
• Check eligibility of a post-discharge CASE MANAGER
• Discuss family’s own WELL-BEING and resources

Outpatient

• Synthesize MAJOR ISSUES for handoff
  – Consider a STANDARDIZED TOOL
• Help families organize MEDICAL INFORMATION/ COORDINATE CARE
• Check eligibility for a CASE MANAGER and track and prepare for SERVICE GAPS
• Discuss family’s own WELL-BEING and resources for relief
• Consider creating a POST-HOSPITALIZATION CHECKLIST
• Ask families to inform the outpatient team of a REHOSPITALIZATION