TransitionsFrom Hospital to Skilled Nursing Facility

Oct 26th, 2012

MN Affiliate of NACNS Conference

Background

• Rapid Process Improvement Workshop- Conducted between one of our high use Skilled

Nursing Facilities (SNF) and Abbott Northwestern Hospital

- Revealed need for improved communication

• Plan- Pilot Program (120 day)- Implement 8 elements identified at the RPIW to

improve transitions of patient from acute care to SNF

• Goal- Reduce 14 day potentially preventable readmissions

by 50%

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Elements of the Pilot

• Enhance computer access for SNF staff• Implement communication order to notify

appropriate personnel of discharge to a SNF• Expand role for SNF “Transition Manager”• Implement the role of a “Transition CNS” at ANW• Pharmacy review of medications• Direct faxing of prescriptions to SNF pharmacy• Provider to provider handoff call• Allina Senior Care Transitions sees patient within 72

hours

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Transition CNS role

• Clinical Criteria for Stability at Discharge assessment prior to transition

• Logistical components of transition (ie order clarification or missing orders)

• Available 7 days a week for discharging patients• Communication with SNF transition manager on

day of discharge• Available to contact for up to 72 hours after

discharge for questions/clarification• Attend (or call) SNF IDT meeting for follow up

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Good catches

• Orders, orders, orders! - 100% of discharge orders needed improvement- Medications, wound care, catheters, follow up instructions,

etc.

• Assessment catches day of discharge- Temp of 99.1, +UC, and decline in functional status. MD

agreed to hold DC. Overnight patient spiked a temp to 103 and had + blood cultures

- Escalating oxygen requirements- pleural effusion found and thoracentesis performed.

- Increased agitation/confusion. Held DC; neurology consulted and found patients diagnosis of Parkinson’s disease was unsubstantiated and Sinemet discontinued.

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Barriers

• Short turnaround time

• SNF regulatory requirements for orders

• System does not support efficiency (ie med indications)

• Medication delays at SNF

• Provider non-engagement

• No CNS prescriptive privileges for pilot

• Large time commitment (barrier to expand)

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Findings and Recommendations

• CNSs bring advanced clinical assessment skills and pharmacology knowledge

• Utilization of prescriptive authority for CNSs could make process more efficient

• Communication skills essential• Requires confidence in knowledge and ability to

express discharge concerns effectively to providers, delaying a discharge if necessary

• Positive feedback from SNF• Review and edit system order sets

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