In most healthcare settings, hospital-based clinicians and their physician peers in the ambulatory setting do not communicate adequately and are not well aligned in terms of patient care management goals. As a result, transitions of care from one setting to another are often poor, e.g., patients being discharged from hospital to home or to Skilled Nursing Facilities (SNF). In addition, key factors in the individual patient's circumstances that adversely affect the recovery process are missed. Unintended consequences include unwarranted re-admissions, adverse events, greater utilization of the healthcare system and higher costs.
Actions Taken/Approach to Solutions:
Leaders from the system hospitals and ambulatory settings were brought together to address care transitions. The Emergency Department (ED) decision framework was changed in order to ensure that only those patients who absolutely required inpatient-level hospital services would be admitted. Clinical algorithms to help ED staff triage patients to home vs. admit were provided; examples included heart failure, cellulitis, diabetic ketoacidosis, urinary tract infection and falls. Inpatient hospital case managers were retrained to move patients as safely as possible to home at discharge with careful follow-up arranged, rather than to SNFs. Fewer SNFs were approved for use and demands for higher service levels by the SNFs were instituted. The hospital discharge process was enhanced by safety checks by nurses engaged in the immediate post-discharge period.
The aforementioned actions resulted in fewer hospital admissions, re-admissions and fewer SNF days. Patients experienced better quality care and savings were significant to the global budgets. (Actual numbers for these changes are proprietary; therefore, are not provided.)