Standardized Process for SNF Transitions Helps Prevent Readmissions
By Melinda Young
EXECUTIVE SUMMARY
Using Lean methodology, Monument Health in Rapid City, SD, created a care transition process that reduces excess hospital days, prevents readmissions, and shortens the time it takes from discharge order to the patient leaving the hospital.
- Case management leaders analyzed pain points using SWOT (Strengths, Weaknesses, Opportunities, Threats).
- They created a standardized process for handling hospitalized skilled nursing facility residents.
- They created lists in the electronic medical record to inform the care team which nursing homes in the state can receive various complex patients.
Case managers often struggle with transitioning patients to skilled nursing facilities (SNFs) when every healthcare organization is facing staffing issues and other barriers to efficient, fast, and safe discharges. The first step to solving discharge issues is to identify the problems, barriers, and possible solutions.
“We used Lean methodology and a brainstorming session to look at what was going well and what our opportunities were,” says Anita Dunham, MS, BSN, CMAC, a senior director of case management at Monument Health in Rapid City, SD.
The solution worked well, helping reduce excess hospital days, prevent readmissions, and shorten the time from discharge order to the patient leaving the hospital.
“When the patient leaves the building, it’s about 50 minutes less now than when we started the program,” Dunham says. “We did a SWOT analysis of all the pain points. We didn’t want to break something that was working well, so we had to look at it and chose to use a methodical approach.” SWOT stands for Strengths, Weaknesses, Opportunities, and Threats.
The health system tackled this problem by forming a group of physicians and allied health professionals. They held a brainstorming session to determine what worked well in the transition process and find opportunities for improvement.
“We had medical directors, directors of nursing from the nursing homes, and case managers,” Dunham notes. “We had governance support, as well as all ancillary services that impact our population, including pharmacy, therapy, and wound care.”
Dunham and colleagues used the following process:
• Validate the regulatory guidelines. Hospitals and SNFs might not always agree on what the regulations require.
“Sometimes, they’re conflicting,” Dunham says. “We looked at the regulations first to see what was required around each issue we were trying to improve.”
For example, long-term care organizations contract with certain pharmacies. “What we heard from nursing homes is they wanted to discharge medications in a certain way because of the regulations followed by the pharmacy,” Dunham explains. “I reached out to pharmacy directors. They said they didn’t need to do things that way, and it was the nursing homes that needed it that way.”
Dunham suggested everyone meet in the same room and talk about what the regulations require and what was needed to provide a safe transition while following the regulations. “What do we need from the medication discharge perspective to standardize that transition?” she asks.
Everyone came to a consensus that helped eliminate the medication variability in care transitions. “We took the information back to the hospitalist, nursing home medical directors, and teams to see what the pharmacist and nursing and hospital had decided,” Dunham explains. “We just wanted to collectively come to a consensus with all the parties that it impacted.”
They made sure everyone — including case managers — was on the same page.
• Obtain transfer agreements. The hospital and nursing home implemented written transfer agreements, says Emily Mills, RN, BSN, manager of the department of case management at Monument Health. The agreement is for the nursing homes to accept the return of residents who were hospitalized for an acute episode.
“Once the patient is medically stable, the nursing homes will accept the patient back within a 24-hour time frame,” Mills adds.
The return of SNF patients became a bigger issue during the pandemic because of the need for COVID-19 patients to be isolated for 10 days, Dunham notes. This was a barrier to sending COVID-19 patients back to their SNF after they were stabilized.
“We were keeping people in the hospital and keeping them in isolation for 10 days when they had COVID,” Dunham explains. “We were doing all those things like other hospitals across the country were doing. Now, we’ve normalized that process and have come to a consensus on moving forward.”
As part of their program to improve transitions and efficiency, they have created a standardized process to handle SNF residents who are hospitalized.
• Integrate changes in electronic medical record (EMR). “We also worked very closely with our EMR colleagues to make sure we optimized our electronic health record’s functionality to make it easier for the entire team to have a standard process to discharge patients,” Dunham says. “We optimized discharge orders in the electronic health record, and we also leveraged our technology to create additional reports that made it easier for nursing homes to have ready access to reviewing key information on the patients they were admitting.”
Electronic referral in the EMR included pre-built lists so the care team would know which nursing homes in the state accepted complex patients, such as those on dialysis. It also included information on the patient’s insurance.
“All of those are pre-built so the team does not have to get the information or remember,” Dunham says. “They can click a few buttons and have that information right in front of them.”
• Roll out standardized process. After the team reached an agreement on the standardized process, they chose a rollout date.
“Effective to this date, our EMR was up to date and more efficient, and pharmacies were all aware of the change,” Mills says. “It helped make the process much smoother to discharge from hospital to nursing home.”
Mills worked with the hospitalist group as physicians handled discharges. She provided them with real-time education on the new standardized process for transitioning patients to SNFs.
“It took about nine months,” Mills notes. “We started in June 2022, and it’s an ongoing process.”
A dozen different nursing homes have adopted the standardized process, and the program is working well, Mills adds.
• Provide resources. Another obstacle to efficient transitions was the shortage of physicians working with SNFs. “We have a shortage in our community of primary care physicians willing to go to nursing homes,” Dunham says.
Monument Health offered a service for local nursing homes as part of their partnership in improving transitions. The health system’s geriatric physicians serve as medical directors at nursing facilities.
“They do all regulatory visits, round the nursing homes, and serve as medical director,” Dunham explains. “This was a service we offered for local nursing homes, and it works very well and complements the work we do in the hospital.”
• Focus on key areas. “We focused on everything this team felt inhibited their ability to have a smooth process,” Dunham says. “Medication was one of many we got a lot of questions about.”
The team identified gaps in care that occur when patients are transitioned to long-term care facilities or nursing homes. “This is where the SWOT analysis comes into play,” Dunham says. “One gap was related to medication, another was discharge orders, and one was around referral and response. If we send a referral to a nursing home, how long does it take you to respond to that referral? What we found was some nursing homes said, ‘If I don’t respond, it’s because I don’t have a bed, I’m not going to have a bed, and I’m doing 20 other things.’”
Case managers interpreted the non-response to mean the SNF was still reviewing the case, and follow-up was needed. This lack of understanding led to long delays in transferring patients. The solution was to change the process and tell SNFs if the case management team did not hear from them within 24 hours of receiving a referral, they would assume the facility does not have an available bed, Dunham explains.
This change helped clarify to case managers about what a non-response meant. They no longer assumed the facility was still reviewing the referral. “We said, ‘We’re moving on,’ and it helped when we talked with family members about the transition,” Mills adds.
• Address denials. Before the program, long-term care facilities would indicate the reason for a referral denial in the electronic referral record. Their reasons were limited to a few items, including staffing and patient complexity.
“If the hospital asked what makes the patient complex, the answer is something we would take back to the physician,” Dunham explains.
Asking for clarification takes time, so the new process includes an expanded list of options. Facilities can select more than one reason for the referral denial. For example, the facility could indicate a denial related to the cost of the patient’s medication. Now that case management has an answer, they can ask the physician if a different medication would work as well for the patient, Dunham says.
The facility also could indicate the patient’s wound care was preventing them from accepting the patient. “We’d ask, ‘What about the wound care is inhibiting your ability to handle that patient?’” Dunham says. “‘If it’s the dressing change, and we can get that down to 15 minutes, can you reconsider?’” The team created a process to handle reconsiderations, she adds.
The team also added color coding in the EMR. Patients given a “red” code by a nursing home are those they do not have the capacity to accept, such as a facility that cannot handle patients who wander.
“The green codes are patients they can easily take with no problem,” Dunham says. “Yellow code is for the ones we need to have more conversations about.”
When a denial occurred, the care team evaluated the reasons to see if they could overcome the barrier. If the answer was no, they moved on.
“Our goal is safe transitions, and we had to work together to figure out what that looks like [for everyone] as we work on our capacity issues,” Dunham says.
Using Lean methodology, Monument Health in Rapid City, SD, created a care transition process that reduces excess hospital days, prevents readmissions, and shortens the time it takes from discharge order to the patient leaving the hospital.
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