Transfer Form Standardizes Communication During Care Transitions

Tuesday, February 11th, 2014
This post was written by Patricia Donovan

Clear patient transfer instructions reduce the risk of readmission.

To improve communication and the quality of information accompanying patients during transfer from hospital to nursing home, Summa Health Systems worked with its preferred skilled nursing facilities (SNFs) to develop physician orders and transfer care forms. Mike Demagall, LNHA, LPN, administrator with Bath Manor and Windsong Care Center, two participating SNFs, describes the development process.

This is the first project that we worked on where we identified with surveys that communication was the number one issue. In addition to a nursing facility process and referral, the physicians’ orders and transfer care form was developed by care coordination.

It took some time to develop this program and form. We were able to reduce the amount of information being sent to the nursing home and provide information that was required for the doctors at the nursing home, which is their system of payment. It provides clear and concise physician orders. It provides extra blank areas for consultants and additional information that may go on there. There is nursing documentation of the plan of care and other nursing information on the other side. The front side is for the physician, and the back side has nursing information and a list of the chart forms that must accompany the patient.

This form took about a year to develop, and we have suggestions on how we may want to adjust the form once or twice a year. In addition to our small care coordination network, this went out to the Akron Regional Hospital Association. As the area SNFs and the Summa Hospital collaborated, that was where they met. The form helped standardize the communication. Additionally, we had the buy-in from the Akron Regional Hospital Association, which several of our members from the care coordination are a part of, as well as Summa Hospital.

They were able to implement that form in the community as a whole, not just between form and the care coordination network.

Excerpted from: Accountable Care Strategies to Improve Hospital-SNF Care Transitions

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