Transitions of Care, Part II: So you know they're eventually gonna have to leave ... right?

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You know you're a nurse when ...
You know you're a nurse when ...
OK, I'm not talking about your kids, because we all know they NEVER leave, and if they do, they keep coming back like boomerangs. I'm talking about your residents. 

Let's face it, one day your resident is going to have to leave the facility. Come on, don't act so surprised. I mean we basically know it happens two ways: the ones we plan for, and the ones we don't.

But guess what, gang: We can plan for the ones we don't plan on! (Hang with me, I know I'm confusing you. Heck, I confuse myself all the time but will make sense in a minute!)

Oh, let me get one pet peeve off my chest. I REFUSE to call a resident leaving any place of service a discharge. First of all, the word itself is just disgusting. Totally gross when you think about it, right? Next, think about what it is we are doing. We are not “discharging” them anywhere. What we are doing is handing them off to another level of service or another provider, even if for a short period of time. So no more discharge. I am NOT defining that one, kids!

According to the AMDA guideline, “Transition of care refers to the movement of patients between healthcare locations, providers, or different levels of care within the same location as their conditions and care needs change.” So understand you are transitioning, even if you are sending them out for a consultant visit, an outpatient diagnostic test like an endoscopy (planned transition), as well as when you are sending someone to an acute care facility like an emergency department (unplanned). 

Let's break this down then. You know that pretty much every one of your residents is going to transition sooner or later. You know this will either be planned or unplanned. So why not get ready for it now, while you have time to prepare for it, when it's not emergent and you're not running around like the proverbial chicken without its head?

Think. What generic information does every resident need to accompany him or her?  (And remember: Keep that payer information SEPARATE from the medical information!) So maybe have the resident's name; medical history; allergies and medication intolerances; copies of advance directives including AND/DNR status (Allow Natural Death/Do Not Resuscitate); and the name and specific contact information for the sending facility (including phone number of facility/wing – unit of facility and charge nurse's name).

Also, the attending practitioner at sending and receiving sites of care; responsible family member/decision-maker; barriers to communication; cognitive issues that impair decision-making; who should be contacted for decision-making; health literacy or cultural issues that might inhibit communication; ability to feed self; special dietary needs (e.g., pureed foods, low-salt diet); prognosis and goals of care; and anything else you deem appropriate.

What kind of form can you obtain or create that can include this information so that all you need to do is add last-minute information? The late stuff could include things such as: reason for transfer (i.e., the acute change in condition or problem precipitating the transfer) along with any acute changes from baseline associated with this transfer (e.g., confusion, unable to walk, unresponsive).

It also could inclued the primary diagnosis for admission to sending facility and all current diagnoses; vital signs; medical devices; lines (e.g., central line, dialysis site, pacemaker); wounds; tests with results pending; consults or procedures ordered but not yet performed; significant test results; current accurate medication list with prescription and non-prescription drugs, with doses and frequency; and anything else you deem appropriate.

Now, how about setting up some processes ahead of time to make things transition along smoother (forgive the pun!). Maybe designate one or more specific staff members who would be responsible for arranging transitions. That could mean gathering the transfer information and who would be available for questions and calls before and after the resident's transfer.

Think about a process for copying and putting together medical information like we just mentioned that transfers with the patient. Designate a staff member who is accountable for implementing this process. And develop a process for contacting (like we said last time — actually SPEAKING to) someone at the next site of care to communicate the resident's needs. That person should also confirm the next site's readiness to receive the resident and its ability to not only deliver the necessary care but understand why the resident is being sent to them!

Oh, and make sure you have someone reviewing the advance directives with the resident and responsible parties as appropriate at every MDS review. 

So, plan for the unplanned.  Now, don't you feel more prepared?

Just keeping it real,

Nurse Jackie

The Real Nurse Jackie is written by Jacqueline Vance, RNC, CDONA/LTC — a real life long-term care nurse who is also the director of clinical affairs for the American Medical Directors Association. A nationally respected nurse educator and past national LTC Nurse Administrator of the Year, she also is an accomplished stand-up comedienne. She has not starred in her own national television series — yet.

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The Real Nurse Jackie

The Real Nurse Jackie is written by Jacqueline Vance, RNC, CDONA/LTC, a 2012 APEX Award of Excellence winner for Blog Writing. Vance is a real life long-term care nurse. A nationally respected nurse educator and past national LTC Nurse Administrator of the Year, she also is an accomplished stand-up comedienne. The opinions supplied here are her own and do not necessarily reflect those of her employer or her professional affiliates.

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