Can't we all just communicate?
A growing focus in long-term care facilities is on the reduction in preventable admissions and readmissions to the hospital. The truth is the timing of this mandate could not be better. Skilled nursing facilities have more registered nursing staff and can handle higher acuity patients than at any time in the past. Many facilities are already providing high level sub-acute care with physicians and nurse practitioners making rounds on a regular basis. In addition, hospitals are becoming increasingly attuned to the importance of safe and coordinated discharge planning to the appropriate level of post-acute care.
Multiple care transitions following hospitalization are hazardous to the patient, but also the reimbursement model for a hospital's revenue has shifted; from providing incentives for admissions to providing incentives for reducing admissions. Hospital systems have been working diligently to improve their discharge planning processes, medication reconciliation, and communication across the care continuum in their efforts to reduce readmissions. So far these efforts have not yielded significant results.
One would expect skilled nursing facility residents to have lower admissions and readmissions to the hospital when compared with community dwellers. In reality, 1 in 4 patients admitted to a skilled nursing facility is readmitted to the hospital within 30 days. In addition, nearly half of all hospital admissions of nursing home residents may be avoidable. This population is the most vulnerable to “transfer trauma” and the negative impact of a fragmented care system.
Our charge, then, is to work within the nursing facilities to identify triggers for hospital transfer, find opportunities to catch signs and symptoms earlier and intervene in the facilities, and leverage all members of the interdisciplinary team to work together toward reducing avoidable transfers.
The essential requirement for these activities is communication. Communication, in turn, requires a common language and a shared care goal. It's not enough to have the team members motivated to talk to one another. They also need be willing to listen, understand and collaborate with one another.
The INTERACT II quality improvement program includes tools to facilitate these critical conversations across the long term care disciplines. This program also provides a structure to facilitate early identification, documentation, and management of changes in patients' clinical conditions. The tools are designed to be incorporated into the daily workings of the nursing facility.
One chronic challenge in communication regarding nursing facility patients lays in the reluctance of the nursing staff to call the medical providers with important information. This hesitation is often due to a history of ineffective communication resulting in strained and ineffective conversations. INTERACT II includes a valuable resource known as the SBAR. SBAR, which stands for “Situation, Background, Assessment, and Recommendation,” provides the nurses with a standardized approach to document and communicate changes in patient condition to the provider that is consistent, efficient, and effective.
Of course, the practitioners must be accessible, attentive, and responsive. They are often frustrated by past conversations that did not provide them with the clinically relevant information needed to make prompt medical decisions. The providers must be informed about the facility's commitment to improve the communication between nurse and provider and be educated on the INTERACT II toolkit. Many facilities have found, once the SBAR is being used on a regular basis by the nursing staff, that the physicians, nurse practitioners, and physician's assistants quickly come to appreciate the more sophisticated reporting. The nurses then feels empowered to communicate their findings more readily and on site patient care will improve. Additional positives include improved discussions between the nurses and the nursing assistants as well as better communication from shift to shift.
Much attention is being paid to the need for improved coordination across the care continuum to protect patients. If we focus first on improving communication within the skilled nursing facility, our patients will benefit before they ever leave the building. Improved communication can lead to improved coordination.
Cathy Lipton, M.D., is the medical director for Evercare in Georgia.