Meetings help improve patient transitions
Meetings help improve patient transitions
Providers bond, improve transitions
When UConn Health Center/John Dempsey Hospital in Farmington, CT, first proposed meetings with post-acute providers to improve transitions, only two skilled nursing facilities and a few home health agencies agreed to participate.
"It was slow going at first. Since the emphasis on preventing readmissions has come to the forefront, we have people asking to join the committee," says Wendy Martinson, RN, BSN, QA specialist in the clinical efficiency and patient safety department. Now there are representatives from 14 skilled nursing facilities, 14 home care agencies, two assisted living facilities, a durable medical equipment and oxygen supplier, a community agency that works with the elderly, and an insurance carrier on the committee. Other organizations that are joining the group include an adult day care provider and a patient advocate.
"Knowing what it's like for post-acute providers has been an eye-opening experience that we have used to improve hospital processes. These meetings have helped foster a true collaboration of working better together across the continuum of care. This team of providers who work throughout the continuum are a dedicated group of people who are really invested in ensuring quality of care," she says.
The hospital started the meetings with the home health agencies and skilled nursing facilities based on common referrals and gradually expanded to include other post-acute providers.
"When we first started the meetings, we feared that it would be a finger-pointing session; however, that truly was not the case. Blame has never entered any of the meetings. We immediately became a cohesive group and with everyone working for the same objective," she says.
The committee meets once a month to address issues that arise as patients transition from one level of care to another and collaborate on ways to improve the quality of care. "We knew that we could definitely improve on communication across settings. Everybody tends to work in their own silo, but we individual providers can't improve transitions alone," Martinson says.
The committee agreed that all providers would use the same educational materials throughout the continuum. They assembled a variety of educational booklets, showed them to patients, and then agreed that all providers would use the materials that the patients preferred.
Based on input from the post-acute providers, the hospital embarked on a quality improvement project to revise the discharge materials to make sure the providers were getting the information they needed. "We are working on increasing the information provided in our discharge instructions, and getting the dictated discharge summaries to providers, specifically the visiting nurse agencies, in a timely manner," she says.
As a result of the meetings, the nurses who care for the patient in the hospital make a verbal report to the staff at the next level of care in addition to the discharge forms sent by the hospital. Social workers also make a report to the next level of care if they have identified social issues. "Sometimes there are family dynamics or other issues that the staff doesn't want to put on paper but that will help the staff at the next level formulate the best plan of care. It's worked well for the nurses and social workers to make the reports by telephone," she says.
When UConn Health Center/John Dempsey Hospital in Farmington, CT, first proposed meetings with post-acute providers to improve transitions, only two skilled nursing facilities and a few home health agencies agreed to participate.Subscribe Now for Access
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