Transition CMs reduce readmissions from SNFs
Nurses work with staff, patients, families
At Western Maryland Regional Medical Center, having nurse transitionists act as a liaison between the hospital and nursing facilities has reduced the readmission rate from participating facilities from 30% to 18%.
- The nurse transitionists carry a caseload of about 70 patients and work closely with the nursing home staff, patients, and family members to improve transitions.
- They follow patients who are admitted from a skilled nursing facility from the time they are admitted and patients who are going to a skilled nursing facility for the first time from the time that they are accepted into a bed and for 30 days after discharge.
- They visit the nursing home within 24 hours of transfer, meet with the patient, family, and staff and answer questions. They return on Day 5, between Day 11 and Day 14, and again at 25 to 30 days.
By establishing a nurse transitionist program to improve communication between the hospital, the staff at skilled nursing facilities, patients, and their families, Western Maryland Regional Medical Center, a 275-bed hospital in Cumberland, MD, has reduced the readmission of patients from participating facilities from 30% to 18%.
"We haven’t completely stopped readmissions, but we have reduced them significantly. Patients in skilled nursing facilities have a lot of issues that bring them back to the hospital, but we are preventing unnecessary admissions," says Carol Everhart, RN, MI, director of care coordination and quality initiatives.
The program was begun as part of an initiative to cut down on readmissions, Everhart says. An analysis of readmission data showed a high volume of readmissions among nursing home patients. A team from the hospital met with the director of the hospital-owned skilled nursing facility and analyzed what was driving the readmissions. "As we looked at the readmissions and talked it through, we realized that poor communication was a major cause," she adds.
The hospital created the position of nurse transitionist to be a liaison between the hospital and the nursing home and work with nursing home staff, patients, and family members to ease transitions. The program started in June 2012 with the hospital’s own nursing home and has expanded to six of the eight skilled nursing facilities in the area. The program now has two nurses who jointly carry a caseload of about 70 patients at any time. "We are very creative in collaborating with the local skilled nursing facilities. For all of us to survive, we know that we all have to work together," Everhart says.
The transition case managers follow patients who are admitted from a skilled nursing facility from the time they are admitted to the hospital. They begin following patients who are going to a skilled nursing facility for the first time from the time that they are accepted into a bed. They visit the skilled nursing facilities to which the patients are discharged for 30 days after discharge from the hospital at intervals determined by peak times for readmissions.
When the position was created, Everhart opened it up to the entire case management staff and interviewed those who were interested. She chose a case manager who had worked at the hospital-owned skilled nursing facility before coming to the acute side. "She already had a relationship with the staff at the nursing home. They trusted her and didn’t see her as a threat. She knew that she was there to help, not to criticize or judge," Everhart says. The implementation went smoothly and when the second case manager transitionist came on board in October 2012 and was trained by the original transitionist, she was accepted readily at the skilled nursing facilities.
"The most important part of working successfully with a skilled nursing facility is being familiar with long-term care, how nursing homes are organized and staffed and how they are different from the acute-care setting. Our transitionists go in as a partner, rather than someone who is there to instruct or judge," she says.
After seeing the success of the program in the first skilled nursing facility, other nursing homes in the area approached the hospital about participating. "This is a small community, and the word spread. Once the program got started, the success was well known and other facilities wanted to come on board faster than we could manage," she says.
The transitionists have an office in the hospital and rotate which of the two is in the field or in the hospital. They cover the nursing facility patients six days a week. Typically, one transitionist is in the office and the other is in the field. Both transitionists work with the staff and patients at all nursing homes. "We do not assign them patients or nursing facilities, so we’ll have cross coverage for all patients. They work autonomously so they can meet the needs of all the patients and family members," she says.
The transition case managers use electronic work lists that track all nursing home residents who are in the hospital and other patients for whom a bed selection at a skilled nursing facility has been made. The unit case managers are responsible for the day-to-day management of the patients, coordinating length of stay and medical necessity. As discharge approaches for patients returning to a skilled nursing facility or transferring for the first time, the transitionist takes over the case.
Since they begin working with the patients and reviewing the medical record while they are still in the hospital, the transitionists understand what happened during the admission and what the discharge plan is, which enables them to assist with the transition into the nursing facility, Everhart says.
The transition nurses visit the nursing home within 24 hours of transfer, meet with the patient, family, and staff and answer questions. They assist with medication reconciliation, explain the treatment plan, and answers questions. "They make sure that the handoff is smooth, that the staff understands the care of the patient, and that everybody is on the same page," Everhart says.
The case managers return to the nursing home to visit the patient, family, and staff on Day 5 to check on the treatment plan and the patient’s progress and to answer any questions. They visit again between Day 11 and Day 14 and again in the 25-30 day timeframe.
"Depending on what is going on with the patient, the nurse may come back earlier than scheduled. The primary focus is to make sure that the transition goes smoothly and that the nursing home staff knows what the patient needs," she says.
When the staff at the skilled nursing facilities feel they need to send a patient back to the hospital, they call the transitionist, who may be able to make suggestions that could help avoid the readmission. Four out of the six skilled nursing facilities use the Interventions to Reduce Acute Care Transfers (INTERACT) tool, designed to improve the identification, evaluation and communication about changes in nursing home residents’ status. INTERACT gives the front line staff, usually certified nursing assistants, guidance on what to do when a patient’s condition appears to change. (For more information on the INTERACT tool, visit http://interact2.net/about.html.)
If patients do need to be admitted to the hospital, the nurse visits them when they get to the unit to find out what has been going on with the patient that might have caused the readmission. The transitionist reviews the patients’ care in the skilled nursing facility, including their diet and activity level. In one case, a heart failure patient came back to the hospital or was taken to the hospital’s heart failure clinic at regular intervals. The transitionist drilled down and determined that the nursing facility had a "Hot Dog Day" and the patient was eating sodium-loaded hot dogs, which exacerbated his condition.
"When the nurses find something that could be causing the readmissions, they talk to the patient about lifestyle changes, such as eating a low-sodium diet or increasing ambulation. They conduct that structured re-education every time they see the patient, not from a scolding standpoint but from a collaborative standpoint to help the patients improve their health," she says.
Nursing facility residents don’t want to come back to the hospital, Everhart points out. "We try to be that stabilizing force that works with all the players to keep the patient in the secure setting that is best for them," she says.
