Critical Path Network

Community network facilitates seamless transition of care

Hospital, nursing homes work together on transfer of patients

After Summa Health System began a series of initiatives to provide a seamless transition as patients move between levels of care, the rate of hospital readmissions within 31 days dropped from 26% to 24%.

"Avoiding readmission is a challenge for every care manager and discharge planner. We identified where the potential risk factors are and came up with strategies to manage them," 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.

The challenge is compounded by the fact that today's hospitalized patients are older and far sicker than in the past and many have multiple chronic illnesses.

"We have an increasing number of patients who are aging with pre-existing functional impairments, as well as lack of caregiver and social support. In the past, patients were admitted with simple pneumonia or heart failure. Today, nothing is simple," Holder adds.

Today, a likely scenario would be a patient with pneumonia who is admitted for a two-day stay. The patient is elderly, living alone, and has functional problems and other comorbidities such as heart failure, lung disease, diabetes, or a complex medication regimen.

"We can't just look at medical conditions. We have to take into account all the risk factors that could prevent these patients from successfully managing their own care, preferably at home or in another level of care" Holder says.

Summa's post-discharge initiatives include collaborating with local skilled nursing facilities on communication issues as well as taking a proactive approach to discharge planning and patient and family education.

"We knew we couldn't do this by ourselves. We have to reach out to the nursing homes and other community providers in order to provide a seamless transition between levels of care," Holder says.

One key factor in improving the transfer process was the development of the Care Coordination Network, a coalition of representatives from the hospital system and 28 nursing facilities in the community.

The goals of the Care Coordination Network are to reduce fragmentation of care, decrease hospital length of stay and unnecessary readmissions, and enhance quality and patient outcomes, Holder says.

Representatives from each of the nursing facilities work collaboratively with hospital staff to improve the way information is shared and ensure continuity of care as patients transition from one level of care to another.

"The network has been a real plus. We are looking at it from both sides when it comes to improving transfer of care between facilities. There would have been no way for us to change the process without knowing what the nursing facilities needed," she says.

The network team identified factors that impede smooth transition, including the time it takes to identify available beds at post-acute facilities and gaps in information the hospital provides to post-acute providers.

One of the first steps was to create a standardized nursing facility transfer form for orders and information needed as patients are transferred from the acute care hospital to the nursing facility. Based on the success of this effort, Summa contributed to the development of a regional post-acute transfer form that is now used for transfers between hospitals and nursing facilities in a four-county area of northeast Ohio. The Akron Regional Hospital Association took a leadership role in the development of the regional transfer form.

"We also asked the nursing facilities to tell us what they need to make a decision on whether they could take the patient. This includes bed availability, patient needs, and other transitional issues," Holder says.

Using the information, Summa implemented an electronic referral process, using an electronic discharge planning product that has increased the timeliness and efficiency.

"As a result of this interaction, hospital staff were educated on what the nursing facilities need and why. Another positive effect of the interaction is the decrease in requests for chart forms to be faxed to the facilities. The network developed a core list of information needed, which decreased work time for the acute care staff," Holder says.

In the past, each nursing facility wanted different information, which meant the hospital staff had to copy as many as 30 or 40 different forms. The facilities got together and narrowed it down to about 14 areas of key information, she adds.

After creating the nursing facility transfer form for regional use, Akron Regional Hospital Association, in collaboration with Summa and the Care Coordination Network, developed a referral form for nursing facilities to use when they transfer patients to an emergency department.

"The communications process goes back and forth. They are telling us what they need from us, and we are telling them what we need from them," Holder says.

All of the nursing homes in the area use the transfer form to give the emergency department staff details on why the patients are coming in. The nursing homes also put a patient identification band on every patient transferred to the hospital or emergency department.

The post-acute care to emergency department/ hospital transfer form provides information about the reason for the transfer and the baseline history and functional level of the patient.

The Care Coordination Network is working to review the quality of patient transfers and to identify factors that contribute to patients being admitted to the hospital within seven days.

"We're looking to see what we could have done differently and to develop initiatives to address them. We are seeing a trend for patients being admitted within seven days with symptoms of delirium," she says.

"Before we started this process, we had no way of knowing why they were coming back. We asked them to critique us and let us know how we could do a better job in providing information about the patient. It really helped us close the loop on what we needed to include when we transfer a patient," Holder says.

At the same time, the hospital system is able to communicate quality issues with nursing facilities, such as how a quick response for bed availability helps with hospital capacity. In turn, the hospital staff learned that when the patient is going to need a particular type of bed, such as for a bariatric care patient, the nursing home needs to know up front.

"They understand that we have to be able to move our patients when we're full. We have educated each other about what each of us needs to ensure a quality transfer," she says.

(For more information, contact: Carolyn Holder, MSN, GCNS-BC, manager of transitional care for senior services/post-acute, Summa Healthcare, e-mail: