A lack of quality information from nursing facilities when a patient was transferred to an ED was one barrier task force members tackled when developing their skilled nursing facility (SNF) care coordination network, explains Mike Demagall, LNHA, LPN, administrator with Bath Manor and Windsong Care Center, and Carolyn Holder, MSN, RN, GCNS-BC, manager of transitional care for Summa Health System.
On the acute care side were the lack of quality information received upon transfer from an acute care to a nursing facility and the lag time in identification of post-acute bed availability. The social worker was calling or faxing information to a facility, and the facility took up to 24 hours to respond as to whether a bed was available. That person may have been ready that day; instead it postponed that discharge another day.
We also had barriers to the patient’s acceptance of the need for post-acute care. Social workers and care coordinators at the bedside tell them when it is time for rehabilitation.
The next barrier was family expectations. Does the family feel that they need to go to the nursing home? The hospital staff and the insurers had to spot the appropriate levels of care. One of the concerns we had was, ‘Is this going to send a lot of our patients ′ our referrals — to home healthcare and decrease our referrals by participating in this?’ That happened to not be the case at all.
There was still a lack of knowledge and respect towards longterm care. All the discharge planning people, which case manager nurses and social workers, were able to tour the facility. Each facility had the opportunity to present their services and what they do. That helped with the overall cohesion of the group, and it moved this project forward.
There was a lack of quality information received from the nursing facilities on the transfer to an ED. That was information that we needed to get back, just as we were asking for information as those residents were coming.
We had the lack of comprehensive assessments from the facility staff prior to the communication to the nursing facility attending physician regarding changes in condition. This was any time of day, but typically the evening or weekend phone calls when you may have an attending that is covered by one of his physician colleagues. We wanted to make sure that we had enough information so that this physician could make an appropriate decision based on true medical information and not the typical call of, “My patient doesn’t look good.” We were able to get them quality information.
Finally, we had the lack of information from patients coming from a post-acute for surgical procedures. These residents have guardian issues, or sometimes there are special needs in equipment. As a facility, we often send the physician orders, and they are able to take care of the patient. There is a significant amount of effort that goes into that on the nursing side, and we were not communicating that to the hospitals for any surgical procedures or any other post-acute care. There were communication barriers with the resident’s transfer to the ED.
Accountable Care Strategies to Improve Hospital-SNF Care Transitions provides a look at a health system-SNF network that has curbed rehospitalizations and length of stay for participants. The hospital-to-SNF transition is one of the top three care transitions addressed by healthcare organizations, behind hospital-to-home and hospital-to-SNF.