Biomaterial Database

Partnerships in Transitions: Acute Care to Skilled Nursing Facility. 2017

Mae L Dizon, and Ruth Zaltsmann, and Cheryl Reinking

Mae L. Dizon, DNP, RN, NP, ANP-BC, is an adult nurse practitioner who has mainly focused on geriatrics. She is the nurse practitioner and coordinator for El Camino Hospital's NICHE (Nurses Improving Care for Healthsystem Elders) Program that aims to improve the care provided to older adults. In addition to this, Mae has been integral in the implementation of the Transitions of Care Program, concentrating on reducing avoidable readmissions for skilled nursing facilities. Ruth Zaltsmann, MS, RN, was an emergency department nurse before joining El Camino Hospital as a program manager to develop, implement, and manage the Transitions of Care Program. In addition, Ruth has spoken at many conferences and webinars focused on hospital transitions work, preventing readmissions, collaborative work within the health care environment, and Medicare's Bundle Payment Care Improvement Initiative (BPCI). Ruth currently serves as a BPCI Clinical Program Manager for Dignity Health and provides consulting services on the topic of health care changes to hospitals and physician groups in San Francisco, CA. Cheryl Reinking, MS, RN, NEA-BC, is currently the Chief Nursing Officer at El Camino Hospital in Mountain View, CA. Cheryl oversees 24 nursing departments as well as laboratory, pharmacy, respiratory care, and clinical nutrition. Cheryl has been in this role since 2013. Cheryl has served El Camino Hospital for the past 20 years in multiple roles including Vice Chief of Clinical Operations, Director, and Manager. In addition, Cheryl is a member of the Magnet committee, which was instrumental in assisting the hospital in achieving Magnet status in 2005, 2010, and a third designation on 2013. Cheryl was recipient of the Silicon Valley Women of Influence Award in 2013.

OBJECTIVE Older adults, in particular those discharged to skilled nursing facilities (SNFs), are at high risk for readmission. As part of a multifaceted approach to reduce readmissions, a community hospital initiated a 3-prong approach (Collaboration, Communication, and Competency) and partnered with regional SNFs. METHODS El Camino Hospital, an independent, locally owned, not-for-profit district, acute care hospital in Northern California, and 11 participating SNFs in the same region. CONCLUSIONS Collaboration: The combined leadership team developed a case report form and instituted regular reviews of 7-day readmissions. Communication: Standardized form for transferring patients to SNFs, form for transfer from SNF to emergency department, and consent form to enable SNFs to administer antipsychotic medications were developed. Regular phone and video conferencing between clinicians at the hospital and receiving SNF were instituted. Competency: Educational series to recognize and intervene to prevent readmission, and mutual exchange of best practices among hospital and SNF staff, were instituted. Continued work among ECH and the participating SNFs has improved the flow of information in both directions; favorable results from the broader study to reduce readmissions hospital-wide provide support for these efforts. CONCLUSIONS Initiating collaboration with the SNFs is imperative in the changing health care landscape. Because of the complexity of the problem, acute care facilities and SNFs need to create a partnership to ensure smooth patient transition. Communication between care settings is essential in achieving optimum patient outcomes.

UI	MeSH Term	Description	Entries
D010360	Patient Transfer	Interfacility or intrahospital transfer of patients. Intrahospital transfer is usually to obtain a specific kind of care and interfacility transfer is usually for economic reasons as well as for the type of care provided.	Patient Dumping,Care Transition,Health Care Transition,Patient Transition,Patient Turfing,Transition of Care,Care Transition, Health,Care Transitions,Care Transitions, Health,Dumping, Patient,Health Care Transitions,Patient Transfers,Patient Transitions,Patient Turfings,Transfer, Patient,Transfers, Patient,Transition, Care,Transition, Health Care,Transition, Patient,Transitions, Care,Transitions, Health Care,Transitions, Patient,Turfing, Patient,Turfings, Patient
D003266	Continuity of Patient Care	Health care provided on a continuing basis from the initial contact, following the patient through all phases of medical care.	Continuum of Care,Continuity of Care,Care Continuity,Care Continuity, Patient,Care Continuum,Patient Care Continuity
D006801	Humans	Members of the species Homo sapiens.	Homo sapiens,Man (Taxonomy),Human,Man, Modern,Modern Man
D000208	Acute Disease	Disease having a short and relatively severe course.	Acute Diseases,Disease, Acute,Diseases, Acute
D012866	Skilled Nursing Facilities	Extended care facilities which provide skilled nursing care or rehabilitation services for inpatients on a daily basis.	Extended Care Facilities,Facilities, Skilled Nursing,Nursing Facilities, Skilled,Care Facilities, Extended,Care Facility, Extended,Extended Care Facility,Facilities, Extended Care,Facility, Extended Care,Facility, Skilled Nursing,Nursing Facility, Skilled,Skilled Nursing Facility