MA STAAR Learning Session

Completing the Transition into Skilled Nursing, Acute Rehabilitation,and Long Term Care Facilities

Laurie Herndon and Kate Bones

Session Objectives

Participants will be able to: • Describe the role community providers can play

in improving transitions in care• Discuss specific strategies for enhancing care

coordination with SNF, Acute Rehab, and LTC facilities

Transitions into SNF/LTC Facilities

• Small Group work:─Describe how a patient and/or family member

would (ideally) experience care as they transition into your setting (i.e., what they might want and need?)

─ Identify three things that you will need to do in order to deliver that ideal system for your patients (i.e., processes that you will have to put in place)

• Report out on your discussions

Digging In-Open Mind

I. Perform an in-depth review of the last five rehospitalizations to identify opportunities for improvement

• Conduct chart reviews of the last five readmissions, transcribing key information onto the data collection sheets (see Diagnostic Worksheet A or INTERACT Quality Improvement Tool).

• Conduct interviews with patients recently readmitted and their family members (If possible, interview the same patients whose charts were reviewed). Next, conduct interviews with clinicians in the community who also know the readmitted patient (physicians, nurses in the skilled nursing facility, home care nurse, etc.) to identify problem areas from their perspective. Transcribe information from these interviews onto the data collection sheet (see Diagnostic Worksheet B).  

 

• Lack of a clear picture of the resident’s entire history, including the severity of the resident’s condition and complications during hospitalization (e.g., C. difficile infection, pressure ulcers, urinary tract infection, delirium);

• Premature discharge from the hospital with unstable clinical condition

• Lack of an available primary provider who is familiar with the resident’s condition and treatment

• Lack of advance directives, palliative care services, and other types of care that prevent readmission to the hospital

• Inadequate availability and consistency of primary care providers for residents

Opportunities Discovered through Diagnostics

Transitions into SNF/LTC Facilities

• Small Group work:─At your table, identify typical gaps in your

clinical setting (3 or more!)

─What have you seen? What gets in the way of patients getting what they need?

• Report out on your discussions

Working Across the Continuum

By understanding mutual interdependencies at each step of the patient journey across

the care continuum, the team will codesign processes to improve transitions in care. Collectively, team members will explore the ideal flow of information and patient

encounters as the patient moves from one setting to the next and then home.

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IHI’s Roadmap for Improving Transitions and Reducing Avoidable Rehospitalizations

* Additional Costs for these Services

Improved Transitionsand Coordination of Care

Reduction in Avoidable Rehospitalizations

Patient and Family Engagement

Cross-Continuum Team Collaboration

Evidence-based Care in All Clinical Settings

Health Information Exchange and Shared Care Plans

Improving Transitions into Skilled Nursing and Long Term Care Facilities

Developing and Testing Changes to achieve an

optimal reception (or return) into the skilled nursing or long-term care facility:

1. Assure SNF staff are ready and capable to care for the resident

2. Reconcile treatment plan and medications

3. Engage the resident and their family or caregiver in a partnership to create an overall plan of care

4. Provide timely consultation when a resident’s condition changes

1. Assure SNF Staff are Ready and Capable to Care for the Resident

a. Develop mutually agreed upon standardized transfer criteria.

b. Receive and confirm understanding of resident care needs from hospital staff.

c. Resolve any questions regarding resident transition status to ensure fit between resident needs and SNF resources and capabilities.

d. Identify an emergency clinician contact for the resident.

2. Reconcile Treatment Plan and Medications

a. Re-evaluate the resident’s clinical status since transfer.

b. Reconcile the treatment plan and medication list based on an assessment of the resident’s status, information from the hospital, and past knowledge of the resident (if applicable).

a. Assess the resident’s and family or caregiver’s desires and understanding of the plan of care.

b. Reconcile the care plan developed collaboratively with the resident and their family or caregiver.

3. Engage the Resident and Family/Caregiver in a Partnership to Create an Overall Plan of Care

a. Use protocols to guide immediate interventions with commonly occurring conditions and complications in the SNF

4. Obtain a Timely Consultation when Resident’s Condition Changes

Your Turn to Plan

• Create your initial action plan using the ACTION PLANNING FORM

• Document plans for your first test of changes using the PDSA FORM

A P

S D

PDSA Worksheet Team Name:__________________Cycle start date:_________ Cycle end date:__________

PLAN: Area to work on: Describe the change you are testing and state the question you want this test to answer (If I do x will y happen?)What do you predict the result will be?What measure will you use to learn if this test is successful or has promise? Plan for change or test: who, what, when, whereData collection plan: who, what, when, where

DO: Report what happened when you carried out the test. Describe observations, findings, problems encountered, special circumstances.

STUDY: Compare your results to your predictions. What did you learn? Any surprises?

ACT: Modifications or refinements for the next cycle; what will you do next?

What is one new thing you learned

today that you would like to test?