Hospital team reaches out to post-acute providers

Consistent education, transitions are targets

Recognizing that the inpatient staff can do only so much during a three-to-five-day hospital stay, the heart failure readmission reduction team at the University of California San Francisco Medical Center collaborates with post-acute providers and outpatient treatment centers to develop ways to improve transitions between levels of care and ensure that patients receive the same education on managing their conditions regardless of where they are receiving care.

Led by Eileen Brinker, RN, MSN, and Maureen Carroll, RN, CHFN, heart failure program coordinators, the multidisciplinary team invited local skilled nursing facilities and home health agencies to meet at regular intervals with hospital staff to discuss ways to provide better and more consistent patient care. About 20% of patients are discharged to a skilled nursing facility. In addition, whenever possible, the hospital makes a referral for a home care agency nurse to assess the patient at home. If a patient whose insurance doesn’t cover home care visits chooses the University of California home health agency, the health system picks up the tab for the visit.

The collaboration with post-acute providers has been eye-opening for the hospital team as well as staff from the skilled nursing facilities and home care agencies, Brinker says.

For instance, early in the program, the team noticed that patients frequently were coming back from one skilled nursing facility after gaining weight, and conducted an analysis to determine the cause. They discovered that the nursing facility served a kosher diet and didn’t have a low-salt option. “We told the facility staff that we couldn’t refer heart failure patients to them unless they had a better dietary option. They were willing for us to work with the facility’s dietician to develop a low-sodium diet for heart failure patients,” Brinker says.

When Brinker and Carroll started working with the nursing home staff, they created scenarios and asked the nurses what they would do if a patient was short of breath or had gained weight. Every time, the answer was “Call 911.”

“We have worked to help them understand that those are just warning signs and to pass on warning signs of a heart failure exacerbation to the physician. Now there is a lot more communication and troubleshooting and the nurses know they can call us rather than automatically sending patients back,” she says.

When the team met with medical directors from two skilled nursing facilities to talk about hand-offs, they learned that often the goals of care were missing from the discharge summary.

The team goes to the skilled nursing facilities and home health agencies and presents in-services on heart failure management. They make sure that the post-acute providers have all the information they need to manage the care of patients after discharge from the hospital.

“With our new electronic medical record, home care and outpatient providers can see our notes and we can see theirs. It really helps in care transitions,” she says.

The team works closely with the nurse practitioners in the medical center’s heart failure clinic and with primary care providers who are treating the patients in the community.

When a patient is admitted with heart failure, the heart failure coordinator sends an e-mail to the entire team throughout the continuum that has cared for the patient, including the home care agency, skilled nursing facility, and the patient’s primary care provider, in addition to the inpatient team. “We connect all the providers. It’s been a very successful endeavor. The providers all share their information about the patient with everyone who gets the e-mail,” she says. As patients progress through the continuum, the clinicians caring for them add information about their progress and share it with the entire “virtual team.”