Hospitals, SNFs team to prevent readmissions
Better communication improves transitions
Executive Summary
Duke Raleigh Hospital participates in a community-wide collaborative of hospitals and post-acute providers but also has developed close relationships with individual skilled nursing facilities.
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Discussions resulted in nurse-to-nurse reports when patients transition.
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The hospital staff provided education on peripherally inserted central catheter (PICC) line care and wound care to nursing home staff.
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SNFs alert the hospital team when patients are being transported to the emergency department.
By improving communication and developing a close working relationship with staff at local nursing facilities, Duke Raleigh Hospital has improved transitions and reduced readmissions from the nursing facilities.
In addition to participating in a community-wide collaborative of hospitals, skilled nursing facilities, and assisted living facilities, the case management staff at the community hospital have visited nursing facilities in person and met with senior leadership to discuss ways they could collaborate for better transitions.
"We have gotten to know the staff at the nursing facilities, and that makes communication easier when patients transition. We have discussed goals and worked on ways to improve the process," says Pat Kramer, Ed.S, CCM, CSW, NCC, director of case management, who visited the nursing facilities with Karen Preston, RN, BSN, CCM, inpatient team leader and care transition case manager.
For instance, discussions with the staffs at the nursing facilities led to a nurse-to-nurse report when patients are being discharged from the hospital to a nursing facility. "The purpose of the calls is to let the nurse know what has been going on with patients during the hospital stay and when they need their next dose of medication. It also gives patients a sense of security when we tell them that the nurse taking care of them is calling the nursing home where they are going so that facility will have the latest information," Preston says.
When they visited the nursing facilities, Kramer and Preston discussed the importance of making sure the patients' primary care physicians receive a discharge summary when patients leave the nursing facility and that patients have a follow-up appointment.
"When patients leave one facility for another, it's a transition, not a discharge. Responsibility for the patient doesn't stop when they are discharged from the hospital or nursing facility. We want everybody to think about the next 30 days rather than just getting them out the door," Kramer says.
When the staff at one of the nursing facilities asked for education for their nurses on peripherally inserted central catheter (PICC) line care, Kramer and Preston arranged for a PICC line expert from the hospital to teach PICC line care for both shifts of nurses. The hospital also partnered with a nursing facility on wound care education.
Preston calls the nursing facilities after patients have been transferred to make sure the facility has all the paperwork and other information it needs to continue the plan of care. For instance, when Preston follows up on patients who were treated for a urinary tract infection, she makes sure there is follow-up lab work. Otherwise, if the infection persists, the patient is likely to have a change in mental status and end up back in the hospital.
"When patients move from one level of care to the other, things can fall through the cracks. The physician at the hospital may recommend a follow-up test in the discharge summary, but the nursing facility doctor still has to order it. We focus on making sure that everybody owns the patient together," she says.
The follow-up phone calls have helped prevent readmissions in several instances when patients left the nursing home against medical advice. "Sometimes patients get to the nursing facility they have chosen and don't like it. In the past, we did not know the patients had left the facility until they ended up back here. Now we can contact the patient and arrange an admission to another facility or arrange for home health and any equipment the patient needs," Kramer says.
Meeting with and getting to know the staff at the nursing facilities has improved communication and helped make the staff feel comfortable calling the hospital if there is a problem with a patient who has transferred, Preston says. For instance, when a patient lost consciousness for a short period of time, the nursing home called Preston, who called the emergency department to communicate the patient's condition and that he was a resident of a facility that was happy to take him back after treatment.
In another instance, a nursing facility contacted Preston about a patient who was having complications and had been to the emergency department twice. "We talked to his doctor and had the hospitalist admit him directly. This kept the patient from sitting in the emergency department for hours and saved an emergency department visit," she says.
The case management directors and medical directors for case management at three hospitals in Raleigh, including Duke Raleigh, began meeting with representatives from local nursing homes in 2011 on ways to improve communication and transitions. "At first, we met with the nursing homes each of the hospitals referred to the most, but then we opened it to all the skilled nursing and assisted living facilities in the area," Kramer says.
The group started out meeting monthly and educated each other on regulations and procedures they must follow and the pressures that each type of organization faces. Now the group has quarterly meetings and invited speakers on a variety of topics such as health literacy and the Interventions to Reduce Acute Care Transfers (INTERACT) tool.
The nursing facilities have started using the INTERACT tool when they transfer patients to the hospital. One chain of facilities put the tool in a red folder so the emergency department staff can find it easily. "This tool is so valuable for patient safety and patient satisfaction. It eliminates duplication and gives us a head start on our treatment plan," Kramer says.
Members of the community coalition serve on subcommittees that focus on various issues. For instance, the education committee has developed a one-page flyer for patients and family members with information aimed at making transitions between levels of care easier. The flyers inform people of what to expect, such as that most nursing facilities don't have private rooms, patients won't be seen by a doctor every day, and beds don't usually have side rails.
"The flyers are unbranded and can be used by any facility. They are written in plain language with health literacy in mind and reviewed by focus groups of patients and family members. We give them this information verbally, but it helps to have it in writing, too," Preston says.
