1. Ensuring Post-Hospital Care Follow-up Rita A Pinto RN Director of Case Management Sturdy Memorial Hospital Attleboro, MA

2. Who We Are Our Cross Continuum team is represented by the following organizations; Sturdy Memorial Hospital, community partners including VNA, SNF, ALF, LTACH, Council on Aging, and Elder Service Agencies. It also includes patient and caregiver representatives. Our service area includes the Attleboros, Mansfield, Norton, Plainville, Foxboro, Rehoboth, Seekonk, Wrentham, Walpole, Norfolk, Sharon and nearby Rhode Island. Our patient population is comprised of 46% Medicare (includes Medicare HMOs), 14% Medicaid (includes Medicaid HMOs) with the remaining 40% private insurers, self pay and free care.

3. Key Changes 1.Perform an Enhanced Assessment of Post- Hospital Needs 2.Provide Effective Teaching and Facilitate Enhanced Learning 3.Provide Real-Time Handover Communications

4. Our Starting Point Initial discussions at our Frontline team Meetings and Cross Continuum Team Meetings identified communication gaps across the care continuum. One key area we sought to improve was information flow between the hospital Emergency Room and facility transferring the patient for an acute event and/or for possible admission.

5. Changes Tested ER physicians noted information gaps on patient transfer to hospital for treatment and/or possible admission. For example, reason for transfer, code status, specific conditions/needs to assist in evaluation, nursing home M.D. contact info to facilitate discussion, and expectations for return based on SNF capabilities. To address these issues, a team led by the hospital Medical Director and comprised of representatives from the ER, Nursing, Case Management, Hospitalists, Medical Directors and Directors of Nursing from several community SNFs was formed.

6. Changes Tested (Cont’d) Discussions revealed that information forwarded to the ER needed to be concise, relevant to the transfer, and most importantly provide the name of the MD to be contacted should questions arise about transfer back to the facility. Discussions also revealed ER MDs and Hospitalists were unsure if SNFs could handle certain treatment protocols, in lieu of admitting the patient to the acute setting.

7. Learning The Team decided on the following: 1. Explore available written communication tools such as Interact and SBAR for continuity across the care continuum. 2. Design a tool to be used by all facilities to capture and utilize critical information effectively. 3. Conduct audit to ensure tool appropriately used by all facilities, with follow up to communicate non- compliance. 4. Manage patient expectation on facility care levels by providing educational materials (handout). 5. Develop grid for physician use with relevant information on what level of care and/or treatment each facility can provide.

8. Learning Get the right people in the room to encourage dialogue and group problem solving for facilitating change. Communicate, communicate, communicate. Speaking face to face resolves issues in real time, rather than creating a prolonged process. With a streamlined care transition process, patients and families have information necessary for more informed decision making. Not all patients require acute hospitalization, and may be better served in a familiar environment when feasible.

9. Next Steps The team is exploring ways to improve patient transfer back to the facility by considering the following: – What relevant information can be provided to the facility prior to the scheduled transfer, i.e. faxing of prescriptions in advance to facilitate better management of pain and psychiatric issues. – Will nurse to nurse handoffs across care continuum facilities improve transitioning of patients.