Reducing Readmissions with Transitional Care Phone Calls Between the SNF and ER
A recent study by the Journal of Hospital Medicine on the “Perspectives of Clinicians at Skilled Nursing Facilities (SNF) on 30-Day Hospital Readmissions” revealed some key insights into the causes of unplanned returns to the hospital.
The study, which collected qualitative interview responses by SNF clinicians, grouped the contributing factors into 5 areas:
- a lack of coordination between emergency departments (ERs) and SNFs;
- poorly defined goals of care at the time of hospital discharge;
- mismatch between patient clinical needs and SNF capabilities related to an acute illness at the time of hospital discharge;
- important clinical information not effectively communicated between a SNF and hospital; and
- challenges in SNF processes and culture.
While many of these issues require systemic culture changes by both the SNFs and hospitals, adding additional transitional care resources can help to lower the risk of some of these contributing factors:
- Transitional care phone calls between the ER and SNF – As the velocity of admissions and discharges increase for both SNFs and hospitals, clinical teams have limited time and resources to communicate the status of mutual patients. As a result, the handoff from the SNF to an ER suffers and the SNF is left wondering if the patient is admitted to inpatient care. Instead of redirecting the key members of the clinical team to spend more time on the phone trying to reach the ER, a non-licensed employee can devote the time to serve as a conduit between these two entities. These staff members, trained and equipped to perform transitional care phone calls, can deliver key insights regarding the patient to the ER and assist with obtaining the details regarding the status of the patient.
- Transitional care calls between the SNF and family pre-discharge – The study cited SNF nurses lamenting that the family members of patients consistently opt to send loved ones to the ER. The nurses said that this decision is due to a general lack of knowledge regarding the capability of the SNF to care for high acuity patients. This misconception by families can be clarified with outreach by a transitional care worker that explains the “yellow flags” and “red flags” that the SNF team will be monitoring and how the SNF team will respond if they occur. Because this information can be missed by overwhelmed families during admission, these capabilities can be reinforced with transitional care phone calls to family during the first initial days at the SNF.
Other factors that contribute to rehospitilizations relate to “automatic” admissions from the ER, as opposed to returns to the SNF. In these cases, the patient is sent to the ER for a procedure that the SNF cannot perform, such as catheter care or a blood transfusion. There was also a stated belief that insurance is influencing hospitals to discharge patients “quicker and sicker” resulting in patients sent to a SNF that are too unstable to be properly treated. While these clinical challenges require significant workflow interventions between the hospital’s and SNF’s most expensive staff, initial achievements can be reached with a minor investment in transitional care phone calls by any level of employee.