1. Allina Hospitals and Clinics
Aftercare Proposal
Jamie Otto / Mike Borell / Emily Keenan
2. Start of
Aftercare
The end for doctors and nurses but
the beginning for patients and
families.
Jamie Otto / Mike Borell / Emily Keenan
3. Allina Mission Statement
Our Mission
We serve our communities by providing exceptional care, as we
prevent illness, restore health and provide comfort
to all who entrust us with their care.
Our Vision
We will:
put the patient rst;
make a di erence in people’s lives by providing exceptional
care and service;
create a healing environment where passionate people thrive
and excel; and
lead collaborative e orts that solve our community’s health
care challenges.
Our Values
INTEGRITY We match our actions with our words.
RESPECT We treat everyone with honor, dignity
and courtesy.
TRUST We act in the best interests of our patients, physicians,
communities and one another.
COMPASSION We create a caring environment for our
patients and one another.
STEWARDSHIP We use our resources wisely.
Jamie Otto / Mike Borell / Emily Keenan
4. Project Purpose Statement
• To explore the information provided to
patients before starting at-home recovery.
• In order to empower the patient, connect
them to caregivers, and make them more
independent and goal-driven in their
aftercare.
• So that Allina can facilitate and encourage
their patients’ aftercare habits and increase
their quality service ratings.
Jamie Otto / Mike Borell / Emily Keenan
5. Current Practices
• Sit down before discharge
• Bulky Packets
• Check-in Calls
• Check-in Visits
• Care Guides
Jamie Otto / Mike Borell / Emily Keenan
6. Case Studies
Judy
Gender: Female
Age: late 50s
Connection: Mother to a child
who had a heart transplant
and has been a patient herself
What worked in the past?
The personal connection between doctors, extended stay patient, and nurses has been great
for her. It became a real community dedicated to the wellbeing of her daughter. She and
her daughter used MyChart to show the multiple doctors they were in contact with what
medications the other practitioners had her daughter on and keep everything in one place.
What would Judy like to see in aftercare?
The family should be included if they will have a large part in the patient’s care, and patients
who aren’t frequent hospital visitors should know what questions to ask.
What would Judy like to see inside of the hospital?
There should be room for family to go and visitors to stay inside of the rooms. There should
also be information about how to take charge of your own care.
How was the communication with the care team?
Fantastic, because she took the initiative and learned how to ask the right questions. After
spending so much time in medical facilities, she has learned how they function and how to
navigate them.
What were some obstacles in aftercare Judy has experienced?
Sometimes, working with a hospice nurse is necessary and other times it is not. She has
experienced both good and bad ones. Also, there needs to be support for people getting out
of surgery since, while she and her daughter did, some people do not have that.
How much access should family or support networks be given?
If it is a child, the parents or guardian should have total access. Otherwise, the patient
should be able to hand pick what information people are given.
Other Comments:
She believes that a patient needs to advocate for themselves and learning how to do that is
really how someone successfully takes charge of their own care.
Jamie Otto / Mike Borell / Emily Keenan
7. Judy
“It was a stressful situation during release and it was hard to
remember what the doctor said later.”
Jamie Otto / Mike Borell / Emily Keenan
8. Budd
"In the case of the elderly or those patients that cannot properly
take care of themselves, their support networks should be the
focus of the aftercare instruction. Either that, or the family and
loved ones should speci cally have a place to go with their
questions."
Jamie Otto / Mike Borell / Emily Keenan
9. Dawn
"They are counting on the people to be independent."
Jamie Otto / Mike Borell / Emily Keenan
10. Caleb
“If someone is not pushing you to do your physical therapy, it’s impossible to do.”
“There’s things we don’t understand as patients, but doctors need to know.”
Jamie Otto / Mike Borell / Emily Keenan
14. The Aftercare Counselor
•Medical Professional/Counselor/Friend
•Bridge between home and hospital
•From pre-release to end of aftercare
Jamie Otto / Mike Borell / Emily Keenan
15. The Aftercare Counselor
•Answers questions to avoid the
revolving door hospital
•Keeps patients accountable for their
health
•Position can be lled by medical students,
psychology students, social work students,
and retired doctors and nurses.
Jamie Otto / Mike Borell / Emily Keenan
17. Changes to Online Care
CONGRATULATIONS! YOUR WEEKLY PROGRESS:
50
Time(mins)
40 Miles
30
20
10
0
Time Vs Miles Ran
You’ve reached your weekly
fitness goal! Celebrate with a
Fruit and Yogurt Parfait. 30
This week
25 Last Week
20
Because you performed at
15
least 15 minutes of Cardio 5
10
days this week, you’ve reduced
5
your risk of heart disease by
0
25%. Miles Ran
Jamie Otto / Mike Borell / Emily Keenan
19. Technological Care
Wireless heart monitors and
pedometers, connected to online
database
Ability to track progress on your
smartphone or personal computer
Retain phone services for those
without Internet access
Jamie Otto / Mike Borrell / Emily Keenan
20. Structure of the
Aftercare Community
CARE GUIDE
SUPPORT SUPPORT SUPPORT SUPPORT SUPPORT
NETWORK NETWORK NETWORK NETWORK NETWORK
Jamie Otto / Mike Borrell / Emily Keenan
21. Structure of the
Aftercare Community
CARE GUIDE
SUPPORT SUPPORT SUPPORT SUPPORT SUPPORT
NETWORK NETWORK NETWORK NETWORK NETWORK
Jamie Otto / Mike Borrell / Emily Keenan
22. Structure of the
Aftercare Community
CARE GUIDE
SUPPORT SUPPORT SUPPORT SUPPORT SUPPORT
NETWORK NETWORK NETWORK NETWORK NETWORK
Jamie Otto / Mike Borrell / Emily Keenan
23. Structure of the
Aftercare Community
CARE GUIDE
SUPPORT SUPPORT SUPPORT SUPPORT SUPPORT
NETWORK NETWORK NETWORK NETWORK NETWORK
Jamie Otto / Mike Borrell / Emily Keenan
24. Services of an
Aftercare Community
Home consultations
Group meetings with other locals in
recovery
Advanced technological care
Personalized support connected to
your own existing community, support
network, and home caregivers
Jamie Otto / Mike Borrell / Emily Keenan
25. Services in the Home
Conversations about recovery
Check-ups with your counselor
Phone calls and online care
In-home cooking lessons with a
licensed dietitian or nutritionist
Jamie Otto / Mike Borrell / Emily Keenan
26. Connections with
Local Area
Jamie Otto / Mike Borrell / Emily Keenan
27. Connections with
Local Area
Jamie Otto / Mike Borrell / Emily Keenan
28. SUPPORT
NETWORKS
C
CARE
GUIDE
Jamie Otto / Mike Borrell / Emily Keenan
29. SUPPORT
NETWORKS
C
CARE
GUIDE
Jamie Otto / Mike Borrell / Emily Keenan