Hospitals, SNFs team up to improve transitions

LOS, readmission rates decline

After Summa Health System and Akron, OH, area nursing facilities formed the Care Coordination Network to improve communication throughout the continuum of care, lengths of stay and readmissions for patients transferred to facilities in the network dropped.

When the network was established in 2003, the average length of stay for patients discharged to network facilities was 7.3 days, says Carolyn Holder, MSN, RN, GCNS-BC, manager, transitional care, for Summa Health System with headquarters in Akron, OH. The figure has been as low as 7 days in previous years, she says. Readmissions within 31 days from Care Coordination Network facilities dropped from 26% in 2003 to 19% in 2010.

"We invited all the nursing facilities in the Akron area to come to a meeting to discuss how they could work with Summa to improve the quality of care, especially as patients transition from one level of care to another," Holder says. "We wanted the nursing facilities to share with us what went well and what didn't go well when patients were transferred from the hospital. They welcomed the opportunity because in the past, they were hesitant to complain because they were afraid of losing business."

Initially, 26 facilities signed a contract to work collaboratively with Summa. The number has since grown to 40 nursing facilities. Joining the network of Summa preferred providers does not involve any financial considerations, but the facilities agree to work collaboratively with Summa to improve quality of care and care transitions.

The multidisciplinary team of representatives from the hospitals and nursing facilities meets regularly to discuss how the transfer process between venues can be improved. Among the initiatives the network has instituted are a new transfer form that the hospital uses when transferring patients to nursing facilities, a tool that guides nursing facility nurses on what to tell the physician when a patient's condition changes, and a transfer form that nursing facilities use when sending patients to the emergency department. (To see copies of the transfer forms, visit the Akron Regional Hospital Association web site at Look under "ARHA Forms" on the left hand side of the page.)

The team members started by examining transfers that were problematic, and they determined that lack of information was the reason in many cases. "We recognized early on that the hand-off between the hospital and the nursing home often was incomplete," Holder says. "We asked the nursing facilities to tell us what they needed and why they needed it."

In some cases, the hospital staff didn't realize the kind of information nursing facilities needed to meet government regulations. For example, if a patient on an IV is transferred to a nursing home, regulations say the nursing home has to have information in their records about when the IV was initiated.

Working with the nursing facilities, the hospitals developed a standardized transfer form that includes the transfer order, a brief patient history from the physician, orders for care in the nursing facility including medications, nursing updates, current treatment plan, information on advanced directives, and information from the patient chart such as therapy notes and medication administration records. As a result of the Summa initiative, the Akron Regional Hospital Association Continuum of Care committee reviewed the form and process with its members. Now all 18 hospitals in the Akron area use a similar transfer form, Holder says.

Skilled nursing facilities typically do not have a physician on staff on the day of the transfer, which means it might be a week or longer before a newly transferred patient is seen by a doctor. "If a nursing facility does not receive complete and clear information, patients may develop problems in the first few days and have to be readmitted to the hospital," Holder says. "These days, patients are sicker than ever before when they go to the nursing home. This means the nursing home staff need a clear set of orders, a detailed discharge summary, and a clear medication list of what the patient is taking when he or she is transferred."

Before a patient is transferred from the hospital to the nursing facility, the patient care coordinator or social worker handling the discharge reviews the transfer form to be sure the nurses and physician have included the details necessary for a smooth transition. The discharge might be delayed until the form is filled out completely.

When the team looked at reasons patients were being readmitted to the hospital from the nursing home, they determined that, in many cases, the nursing home physicians weren't getting enough information about changes in patients' conditions from the nurses at the skilled nursing facilities. "Sometimes the nurses would call the physician and just say that the patient didn't look right and without specific information, the physician would send the patient back to the hospital as a precautionary measure," Holder says.

The Care Coordination Network developed a Change in Condition tool that assists the nurses in organizing the information about a patient's symptoms and presenting it to the physician. Now the nursing home nurses use the Situation-Background-Assessment-Recommendation (SBAR) form when communicating with physicians. (For details about the SBAR form, see

Hospital representatives reported that many times, when patients were transferred back to the hospital from the nursing home, the emergency department staff didn't have complete information on what symptoms brought back the patient. The team created a standardized emergency department transfer form that nursing facilities use when sending patients back to the hospital. The one-page form has space for information on the patient's chief complaint, current medication, recent laboratory and test results, vital signs at time of transfer, advance directives and Do Not Resuscitate (DNR) status, and other pertinent information.

Staff at the nursing facilities were concerned that the social workers and discharge planning staff were unfamiliar with the services each facility offered, so they worked to raise awareness. The nursing facilities have provided transportation to their facility for discharge planning staff to take a tour. In addition, each nursing facility presented their facility at a discharge planning staff luncheon. One brought a patient to their assisted living wing to talk about what it was like to move from home to assisted living.

"We want our patients and family members to have good choices. Because of the Patient Self Determination Act, we can't make recommendations, but we can give them the information they need to help them choose," Holder says.