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Critical Path Network
Proactive approach speeds discharge
CMs identify self-care deficits, educate patients
When the clinical nurse specialists and case managers at Akron, OH-based Summa Health analyzed the reasons patients were being readmitted within 31 days, they determined that mobility issues, self-care deficits, pain control, and failure of discharge planning were key factors.
"We found that the No. 1 reason for readmissions was that the patients lacked the ability to take care of themselves. These patients were cycling in and out of the hospital and not getting better," says Carolyn Holder, MSN, GCNS-BC, manager of transitional care for senior services/post-acute for the integrated health care delivery system in Summit County, OH.
In the Summa system, patient care coordinators with an average caseload of 16-17 patients, monitor and guide the plan of care and collaborate with social workers to coordinate the discharge plan.
Summa uses an initial nursing assessment form originally developed for its acute care for elders unit throughout the hospital. In addition to the current medical condition, the assessment form includes items on functionality, activities of daily living, cognition, depression, and a discharge planning screen to identify support at home prior to admission.
The emergency department starts the assessment form and shares any key information verbally with the unit team when the patient is admitted.
Most of the assessment takes place on the nursing unit.
"The patient care coordinators see their patients on Day 1 and start looking at their functionality, what they need to get back home, what are the barriers that may impede recovery or cause delays in stay. We try to gather as much information up front as possible when they are admitted so we can better plan the discharge and eliminate any roadblocks to a safe discharge," Holder says.
The care coordinators and social workers take the lead in making sure the patient moves through the continuum as quickly and safely as possible, interfacing with the family, the patient, and the physicians to make sure the plan of care is followed.
"We try from Day 1 to get a feel for what kind of care they will need after they leave the hospital. We ask for a physical therapy evaluation on Day 1 and talk extensively with the family to get details about the patient's functional level," Holder says.
Often, the team finds that the information gathered from the patient during the initial assessment isn't 100% accurate.
"Many times, the patient is too sick to give us a lot of details or doesn't want to tell us how many problems he or she has been having. We confer with the family and share the information with the physician," Holder says.
The patient care coordinators and social workers have collaborated on efforts to improve the process and worked to improve communication about what the patients and family members can expect at discharge and what they would need to be able to do at home.
The team is currently looking at the kind of instructions that patients and family members need in order to manage at home.
"We know that the discharge instructions must be in writing as well as verbal and that they must be reinforced throughout the stay," Holder says
The team uses an electronic post-acute referral process for nursing facility placement.
"As soon as we know a patient is going to need skilled care after discharge, we send out information to multiple facilities so that the families can begin to make choices early in the stay," she says.
An assessment nurse from Area Agency on Agency screens patients for eligibility for home health services provided by their PASSPORT program. PASSPORT is a Medicaid program designed to keep older adults at home instead of at a long-term care facility through a range of supportive services.
"The patient care coordinators ask for an assessment on every patient they think may be eligible so they can get long-term services in place as soon as possible," Holder says.
The Summa care coordinators also work with the PASSPORT care managers to ensure continuity of care for patients already active in the PASSPORT program.