1. SNF Circle Back Shannon M. Jackson MSW, LISW, ACM Jacqueline Mikuleza, RN BSN CPHM

2. The Hospital to SNF Connection

3. The why… It’s the right thing to do The SNF Circle Back process began to address patient safety when transferring patients across the continuum of care. Previously, there was no assurance that the patient arrived safely or that written information received by the facility was accurate or timely.

4. 2012 Discharge Disposition

5. SNF Placements by County 2012

6. Reengineering SNF Transfer Determine top Volume SNF’s Using Allscripts Referral data Leadership and SNF’s meet to discuss process and formulate questions Meeting with CNE Meet with top volume SNF facilities Pilot process On paper with RN And SW staff Bedside RN start Calling report To SNF’s Build questions Electronically In Allscripts, Formal rollout housewide Monthly meeting to analyze data/trends Begin calling SNF at discharge to ensure Excellent handoff/transition Quarterly meeting with SNF to address Data/readmissions Staff team builds workflow process in Allscripts

7. Objectives Ensure a safe and successful discharge has been made Review any red flags or warning signs of a possible readmission Answer clinical questions for the receiving provider Ensure customer service with the receiving facility Ensure treatment plan has been communicated Decrease 30 day SNF readmissions to acute care

8. Post Discharge to SNF (24-48 hours) The Process SW, CCC call SNF facility Focus on resolution of any problems Scripted questions located in Allscripts –Did the patient arrive safely? –Method of transport –Did you find admission packet in order? –Were the medication orders correct? –Does the patient’s presentation reflect the information you received? –Have we provided you everything you need to provide excellent care to the patient?

9. Transition Call Back Detail

10. Identified Opportunities/Areas to Improve Transporting agency handoff Outpatient Dialysis arrangements Patient/family choice and preparation Admission/Discharge medication reconciliation process Discharge narcotics prescriptions Escalation of medication questions with prompt resolution

11. Taking Ownership For Post Acute Transitions Transition Data CollectionCommunicationInformation Sharing Performed timely SNF circle back calls; data collection. SNF personnel surveyed with emphasis on safe transition and handoff Acute care RN and receiving SNF handoff Focus on quick resolution of problems Monthly drilldown with SW team Feedback to nursing units Problematic areas determined via root- cause analyses, targeted for improvement

12. SNF Collaborative Partner with high volume SNF facilities Focus on transitions and readmissions Data sharing and collaboration Develop process based solutions together Source: Allscripts Top Ten SNF referrals

13. Observed to Expected Readmission Rates SNF Discharge Status Source Premier 3M

14. 14 Skilled Nursing FacilityCases 2011Readmit 2011O/E 2011Total Placements 2012 Readmit 2012O/E 2012 Facility A4791001.55457691.08 Facility B393901.55405631.08 Facility C289451.10243341.02 Facilty D288270.74398440.83 Facility E228210.70222270.91 Facility F177250.97156120.57 Facility G174381.37135190.88 Facility H153221.00149281.40 Facility I144301.34153241.07 Facility J137241.13176401.35 Facility K134180.89143140.61 Facily L125181.07135100.58 Facility M124110.59175220.9 Facility N112110.59192180.72 Observed to Expected Readmission Rates by Facility Premier custom query using Referral Data

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16. Key Lessons Learned Never make assumptions, everyone needs to take ownership and ensure safe patient handoff Forms are a useful tool; but themselves do not create transitions in care Verbal communication as well as electronic and written communication is essential The call-back process created a means for rapid resolution of problems (within 24-48 hours of discharge) Calls provide immediate opportunity for consumer to give direct feedback It is key to involve the staff who will doing the process itself Doing the right things takes hard work and at times extra steps Involve the continuum of care and the community stakeholders in the process design

17. Key Carolinas HealthCare SNF Circle Back -2- SNF Circle Back Questions 1. Did the patient arrive safely? 2. Did you find admission packet in order? 3. Were the medication orders correct? 4. Does the patient’s presentation reflect the information you received? 5. Is patient and/or family satisfied with the transition from the hospital to your facility? 6. Have we provided you everything you need to provide excellent care to the patient? Insights Transitions are a PROCESS (forms are useful, but only a tool to achieve intent) Best done ITERATIVELY with COMMUNICATION Source: Emily Skinner, Carolinas Healthcare System