Hospital, post-acute providers collaborate on transitions

When an analysis of readmissions indicated that a significant number of patients being readmitted within 30 days had been discharged to a post-acute provider, TMF Health Quality Institute, the Texas Medicare Quality Improvement Organization (QIO) established regular meetings with hospitals in the community, including Valley Baptist Medical Center in Brownsville, TX, and downstream providers including skilled nursing facilities, long-term acute care facilities, home health agencies, dialysis units, hospice providers, and rehab hospitals in the Brownsville area.

"The purpose of these meetings is to break down silos of care and to brainstorm on ways we could facilitate communication and coordination of care at transition. We also want to help participating providers share accountability and understand that readmissions are a community problem," says Robin Jones, RN, quality improvement coordinator Valley Baptist Medical Center-Brownsville.

The meetings, called Regional Workgroup meetings, are held quarterly. Participants discuss barriers to successful transitions and brainstorm on how to improve communication and coordination of care at discharge. The team from the hospital collaborates with case management and other staff at the post-acute providers to make sure that they are getting the information they need.

The home health agencies reported that they were getting inconsistent discharge information or were getting it too late. As a result, the team worked with the hospital case managers quarterly to develop ways to ensure that the home health agencies received all the information they need in a timely manner. "When we followed up with the home health agencies, they indicated that they were getting what they needed from our facility," Jones says.

Using the Situation-Background-Assessment-Recommendation (SBAR) form, the hospital's readmission reduction team created SBAR pocket cards as a tool to help their staff effectively communicate information to the receiving facility as patients transition through the continuum. (For details about the SBAR form, see:

When the hospital analyzed readmissions from skilled nursing facilities, it determined that many readmissions occurred because the skilled nursing facility staff did not recognize early warning signs and symptoms that indicated a patient's condition was exacerbating. "By the time they did realize that the patient was in trouble, he or she was sick enough to be admitted," Jones says.

The TMF Health Quality Institute team educated the entire skilled nursing facility staff, beginning with the housekeepers, to recognize subtle changes in the patients. "The housekeepers probably spend more time with the patients than anybody. We educated them on the signs to watch for and when to notify the nursing staff of slight changes," Jones says.