Hospital and SNFs collaborate on transitions

Continuity-of-care department spearheads effort

By working closely with a carefully chosen network of skilled nursing facilities, The Methodist Hospital in Houston has smoothed the transitions in care for patients being discharged to the facilities.

The hospital created a continuity of care department two years ago with the mission of improving the quality and safety of transitional care.

"I was a director of case management and social work for many years, and I know that all hospitals work very hard at making things go smoothly when we discharge patients, but the truth is, we don't know what happens after patients leave the hospital setting," says Lynda Collins, MSSW, LCSW, director of continuity of care at the 900-bed hospital.

Sometimes patients and post-acute agencies have the perception that hospitals are just dumping their patients, she says.

"I know this is wrong, but it seems to patients and community agencies that we just discharge patients with no help. I felt that we needed to make formal connections to those places where we discharge the patients," she says.

The department was organized partly in response to a throughput problem, which often led to patients being held in the emergency department or the post-acute anesthesia care unit when there were no acute care beds available.

"We had patients who were ready to move to the next level of care but were still in the hospital. We know that patients in the emergency department or the PACU are definitely sicker than patients at the end of their stay. We needed to find out why the patients were staying when they were ready to be discharged," she says.

The hospital created an advisory council that includes Collins, a geriatrician, a PhD nurse with many years of experience in the long-term care arena, two managers from the case management department, and an operational vice president of nursing.

SNF horror stories

Collins and her team analyzed the throughput issue to determine the reason that patients were staying when they were ready to be discharged.

With almost 90 skilled nursing facilities in the area, the team knew that the problem was not a capacity issue.

"What we found was a hesitation on the part of the physicians to refer patients to a skilled nursing facility and a lot of reluctance among patients and family members to leave the hospital for a skilled nursing facility. They had heard a lot of SNF horror stories," she says.

The team looked for ways to address concerns about quality and to address the fact that some patients are harder to place than others. They wanted a way to educate the physicians and families that skilled nursing facilities can provide the kind of care that some patients need.

"I know from personal experience that when the time comes for a loved one to go to a skilled nursing facility, it's difficult even though you know it's the right thing to do," she says.

The hospital invited about 150 skilled nursing facilities in Harris County and the surrounding counties to come to a meeting.

"We let them know that we were going to affiliate with a small number of skilled nursing facilities that were interested in working closely with us to make sure the transition was smooth and safe, that the patients received high-quality care and didn't bounce back to the hospital," she says.

A combination of two or more members of the advisory council visited every skilled nursing facility before they were accepted into the network and researched quality data and other information about the facilities before signing them up.

SNF network created

The hospital ultimately signed an affiliation agreement with 26 skilled nursing facilities, creating the Methodist Skilled Nursing Facility Network. The agreement says both sides will work together to improve care and ensure a smooth transition.

The network met frequently in the first year of the program and now meets quarterly.

"We got a lot of feedback from the skilled nursing facility representatives, and we learned a lot about some things we could do better on our end. The SNFs agreed to take patients six days a week and for longer hours. We offered clinical education for the staff at each facility and, because of the size of the hospital, they knew they would get a high volume of patients," she says.

The arrangement has been a win-win proposition for all involved, Collins says.

The hospital now sends more patients to the SNFs in the network than in the past and the SNFs make the decision to accept patients more quickly.

"Our physicians are more comfortable because they know that we are monitoring the quality at these facilities and we don't lose sight of the patients we send there," she says.

At the outset, the team worked with representatives from the skilled nursing facilities to determine what kind of information the receiving facilities want when a patient is transferred.

They developed a new easy-to-read transfer form based on the information the facilities said they needed. Collins is working with the hospital's information technology department to develop a way to transmit the form electronically.

"When we talked with representatives from the SNFs, they talked about the problems they face such as what happens if a patient comes late in the day or if the facility doesn't have complete clinical information. We learned a lot about the impact on the patient's transition if we don't do everything on our end to give them the information they need," she says.

The facilities in the network have assigned a clinical liaison so that staff have one person to work with when patients are transferred. Many of the facilities send the liaison to the hospital to assess the patients and collect the clinical information.

"They give us a lot of attention and respond very quickly," she says.

In the past, the skilled nursing facilities sometimes sent patients back to the emergency department if the clinical picture wasn't what they expected.

For instance, in the past, the staff would fax over clinical information and lab values, but sometimes patients developed other symptoms before they arrived at the SNF or the lab values changed.

Now, the SNFs have contact information for the patients' nursing unit and Collins so they can work through the issues without bringing the patient back.

"We want to do the right thing for the patients, but moving them back and forth is not the best way to handle any problems that arise. In the past, nobody's job was to look at the overall picture. Now we can answer questions and address things without having to move the patient back," she says.

The hospital has created a web-based map with the locations of all 26 facilities. Case managers can use the map to show the families facilities in their neighborhood so they can visit before making a choice.

"The feedback from our patients and the SNFs has been very positive. This program has benefited everyone," she says.

(For more information, contact: Lynda Collins, MSSW, LCSW, director of continuity of care, The Methodist Hospital, Houston, e-mail: LCollins@tmhs.org.)