“It was then we had an ‘AHA’ moment.”

Assisted Living and Skilled Nursing Facilities Help Determine Steps for Reducing Readmissions

In Pennsylvania and across the United States, the healthcare community continues to see a substantial number of patients readmitted to the hospital. According to the Pennsylvania Health Care Cost Containment Council (PHC4), in 2008 there were nearly 58,000 readmissions in PA which cost $2.5 billion dollars1. Hospital readmissions equal higher costs and less quality care, so what is being done about it?

With Transitions of Care at the forefront of AF4Q – South Central PA’s focus  for 2011 - 2013, the alliance’s nurses council is collaborating with skilled nursing facilities and assisted living facilities to reduce readmissions and improve the care for older residents in our community.

“The hospital readmission rate for skilled nursing facilities and assisted living facilities can be high. Many factors affect unavoidable readmissions, including poor communication. Therefore, we as a team want to start with these groups and then eventually expand into rehabilitation centers and primary care practices,” stated Samantha Obeck, AF4Q – South Central PA Nurses Council leader.

The first step was to fully understand what is causing unnecessary readmissions. The council invited assisted living and skilled nursing facilities to come together and discuss what’s happening, why it’s occurring, and what can be done about it. According to Obeck, “It was then we had an ‘AHA’ moment.”

Both the nursing staff and physicians whom attended realized there’s room for improving communications on both sides. According to the assisted living and skilled nursing facilities, they’re supposed to call the physician when there’s a change in a resident’s status. However, the participating physicians assume the facilities are calling because they cannot handle the situation and wish to transfer the resident to the hospital. The reality is the facility and nursing staff may be well equipped to provide the care that is needed. In the end, the entire situation isn’t being reviewed and assessed; therefore, the misunderstanding drives the parties to send the patient to the hospital – when perhaps they really don’t need to go.   

Based on these findings, AF4Q’s nurses council wants to design safe and reliable transition processes, and coordinate care across each of these settings. To start, a technique known as SBAR ( Situation, Background, Assessment, Recommendation) may be used to structure the communication between members of the health care team regarding a patient's condition. It helps put the focus on communicating about the current situation as well as the patient’s background, and then making recommendations from a full assessment. It provides expectations for what should be communicated, and how to do so with each member of the health care team.

SBAR was introduced to the health care industry in the late 1990s, and has been adopted by hospitals and care facilities around the world. “It is a great way to open the communication between health care staff. Every hospital, assisted living facility, primary care practice is in a different place with technology, using different formats for forms, and sometimes the information isn’t user-friendly. We want to be able to work together, so we can communicate in a similar fashion across the board. This way the information can be understand by everyone and the patients are receiving high quality care,” stated Obeck.

SBAR is a great tool, but AF4Q has also discussed adding another letter to the acronym – the letter T. SBART would add TeachBack into the communication process – which in the end ensures everyone has the same understanding because it involves repeating back what the person’s been told. This provides clarity and continuity of care,” she said.

“We have a lot of ideas and techniques that are really beneficial to reducing readmissions. It’s exciting to see what could transpire as we expand from the preliminary stages,” added Obeck.

To join the Nurses Council, or to learn more about theinitiatives surrounding Transitions of Care, contact Chris Amy, Project Director for Aligning Forces for Quality – South Central PA at (717) 801-4823.



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