Improve Communication and Decrease Skilled Nursing Facility Hospital Readmissions Utilizing Transition Tools and Collaborative Partnerships

Background of the problem: Transitions can greatly impact hospital readmission risk when there is a gap in communication. An absence of a standard process to facilitate communication between the skilled nursing facility (SNF) and patient care team leads to gaps in information related to patient’s plan of care, medication management and continuity of care.

Literature review: Communication tools, care coordination, and collaboration between SNFs and patient care team support patient continuity of care and reduces patient risk for 30-day readmission. Care coordination of patient transitions reduces readmissions. Health information technology tools facilitate communication and reduce patient risk.

Objective/purpose: Establishing a standardized process of communication between SNF and primary care providers fosters partnerships and reduces fragmentation of patient care with SNF transitions. Utilizing a health information technology (HIT) web- based tool, CarePort, facilitates communication of patient information and supports care coordination of patient care that occurs with SNF transitions.

Methods: Established partnerships and implemented standardized process of communication with SNFs to support communication of SNF patient transition information. Standardized communication of SNF patient transitions using templates and technology tools. Standardized communication tools, with use of templates, to support patient SNF transition care between the SNF setting and primary care practice team members, population health medical assistant (PHMAs), HIT team, and primary care coordinators. Implemented standardized process of communication with SNF and primary care team, with the use of CarePort portal, for monitoring SNF patient transitions and outcomes. Establish and increase collaborative partnerships with SNF care team to support communication of transition patient information, using standardized documentation, technology, and CarePort portal. Utilize technology to collect, store, monitor, track, and communicate patient information and data related to patient SNF transition status. Utilize CarePort technology portal tool to support communication of SNF patient transitions.

Outcomes: Improvement of communication between SNF and primary care team members in 6-month time period. Increase # of SNF telephone contacts from primary care team. Increase # of SNF partnerships formed through CarePort portal. Reduced 30-day hospital readmissions of SNF discharged patients with implementation of standardized communication tools. Standardization of communication tools and collaborative partnerships supports communication of SNF patient transition information and bridges transitions from SNF setting and primary care. Communication tools and collaborative relationships facilitate and support care coordination of patient transition care with SNF and primary care settings.

Conclusion/implications for nursing practice: Developing standard processes of communication between SNF and primary care team members supports patient transition care and decreases readmissions. Establishing collaborative relationships and utilizing technology supports continuity of patient care across the continuum. Standardized communication tools support communication of patient information between SNF and primary care practices and foster team collaboration.