Lowering readmissions means getting to know your SNF
At Christiana Hospital in Newark, Del., they have seen a significant decrease in their readmissions from SNFs for certain conditions after making some relatively minor changes, said Dr. Thomas Mathew, a hospitalist with IPC who works at the hospital and is a medical director at two area SNFs.
They started by bringing a small group of hospitalists, nurses, and patient care facilitators over to a nearby SNF and talking about how the facility works and what information the SNF providers needed. The result was that they streamlined the discharge information that they sent over to the SNF and instituted standard provider-to-provider phone calls before patients were discharged from the hospital.
Instead of a stack of information from the patient’s stay, the hospitalists now identify some key information about the patient: an up-to-date medication history, a discharge summary, and a disease-specific clinical summary. For instance, heart failure patients are now discharged with a clinical summary sheet that includes their medications, current lab results, results of critical tests, the name of the cardiologist, and the patient’s recent weights, Dr. Mathew said.
Understand the SNF
Part of the reason that Dr. Young and others suggest that hospitalists visit SNFs when they can is to learn the capabilities of the facility as well as what unique workflow or regulatory issues could be preventing the providers there from following through on some of the hospitalists’ discharge instructions.
Often, patients end up being readmitted to the hospital because they have higher acuity needs than the SNF can handle, said Dr. Zinzella Cox. And some facilities are better at managing patients with dementia, for example, either because they specialize in that type of care or they have a different staffing model. "[Hospitalists] really do need to become knowledgeable about their nursing home facility partners," said Dr. Zinzella Cox, who serves as medical director at several post-acute care facilities in Delaware.
Another common issue arises when transferring patients who need narcotics. The Drug Enforcement Administration doesn’t allow physicians to voice order Schedule II drugs over the phone, and since many patients arrive at SNFs in the evening when a physician isn’t on site, they can’t immediately get the narcotics they need. Some hospitalists get around this issue by premedicating patients before they leave the hospital and then sending them to the SNF with a prescription already written.
Hospitalists are asked to write orders based on the information they provided to the SNF. "Usually this knocks people's socks off. They say, "How am I supposed to admit the patient? I don't know this, this, and this."
This is a good start, Dr. Zinzella Cox said, but hospitalists need to be sure that the prescription is written for a specific quantity administered at specific time intervals. Prescriptions that include ranges for administration don’t comply with SNF regulations, she said. If the prescription isn’t valid, the physician at the SNF will have to write another, which can lead to delays.
It all gets back to talking with the SNF providers, she said. "We really do need to communicate issues between the two care settings so we can work collaboratively together," Dr. Zinzella Cox said.
Practical tips for improving transitions to SNFs
Dr. Young offered some pointers on how to improve the transition from the hospital to skilled nursing facilities:
• Know the environment to which you’re sending patients. There is a large variation in capability, ownership, specialty units, and staffing among SNFs. Ask if they have access to your hospital’s electronic health record.
• Be thoughtful about the discharge paperwork you send. Ask the SNF physicians what information they need.
• Do a postdischarge follow-up phone call. Does the facility need more information? Were the discharge orders implemented?
• Educate patients and families. Patients need to understand that a SNF is not a hospital and they likely won’t be seen by a physician every day.
• Use your tools. Work with a state Quality Improvement Organization to get data on the readmission rates for post-acute care facilities in your area.
For hospitalists interested in starting a quality improvement project with their SNF colleagues, the Society of Hospital Medicine will be posting resources online this fall. The SHM Post-Acute Care Task Force is designing an online toolkit that will include best practices and recommendations on how to get started, Dr. Young said.
mschneider@frontlinemedcom.com
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