Transitions From Hospital to Skilled Nursing Facility

1. TransitionsFrom Hospital to Skilled Nursing Facility Oct 26th, 2012 MN Affiliate of NACNS Conference

2. 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%

3. 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

4. Transition CNS role Clinical Criteria for Stability at Discharge assessment prior to transition Logistical componentsof 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

5. 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.

6. 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)

7. 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