The interventions for Project 3 focus on four main areas: facilitating communication, accurately assessing and addressing patient needs, building stronger relationships between providers, and improving the quality of information exchanged during the care transition. Each one encourages collaboration between the hospital and skilled nursing facilities (SNFs) in order to enhance patient safety and improve the quality of patient care.
Clinical Calls to SNFs
The Project 3 team is working with frontline staff at Yale New Haven Hospital (YNHH) and local skilled nursing facilities (SNFs) to implement a clinical call between sending and receiving providers. Before patient discharge, a sending clinician from the patient’s hospital care team will call the receiving SNF clinician to give report. The report should provide anticipatory guidance for the clinician assuming care for the patient. The SNF physician or advanced practice provider receiving the call should have the opportunity ask clarifying questions.
The outcomes for the clinical call intervention include unplanned hospital readmissions, unplanned emergency department utilization, and scores on an annual care transitions survey administered to SNF clinicians.
After a pilot run in spring 2016, a full intervention was launched in fall 2016. Our partners include teaching and hospitalist units from the general medicine service at YNHH, the care management department at YNHH, and twenty SNFs in the greater New Haven area.
Epic Care Link Walk-Through
In spring 2016, Project 3 brought together a small group of hospital providers, SNF providers, and hospital information systems staff to run a comparison of their views and access within Epic Care Link, the Yale New Haven Hospital electronic referral system for SNF placement.
A facilitator walked the attendees through the entire referral process, from initial request through SNF acceptance. Hospital and SNF user views were displayed on side-by-side dual monitors, allowing the group to compare views while they asked questions, shared concerns, and offered ideas for improvement. The topics often focused on clarifying communication about patient needs and options for care, including locating notes and evaluations, refreshing the request with updated information, and providing more detail about placement decisions.
In direct response, the referral request was amended to include pending lab tests (e.g. flu, MRSA) in order to allow SNF providers to better prepare for patient care. The information gathered in this session was also shared in a community meeting with post-acute care providers for additional input.
Patient Discharges to SNFs Survey
During process analysis, SNF respondents described a range of challenges with care transitions. Some of these challenges were related to hospital readmissions, but others reflected respondents’ broader concerns about the quality and safety of the transfer process. The YNHH Patient Discharges to SNFs Survey was developed to capture these concerns and measure SNF clinicians’ experiences with patient discharges from YNHH.
The initial survey was administered in summer 2016 and completed by 92 respondents from 22 SNFs, representing an overall response rate of 74.80%. The results show opportunities for improvement, notably in improving communication about the plan of care and enhancing the notifications and timing of discharges.
The survey will be distributed again in summer 2017 as a post-test for interventions, including the clinical call to SNFs. The data will also be used to assess the intervening variables that affect the hospital-SNF care transition and support further quality improvement initiatives.