With quality metrics increasingly driven by patient satisfaction, the urgency of smoothly transitioning patients from one care setting to another is ratcheting up for both skilled nursing and home health providers.
A core set of principles and protocols can improve workflows, increase patient outcomes and create a “halo effect” that results in positive ratings, insists Laurie Nelson, RN, BSN, director of clinical innovation for CareXM, a technology platform that helps providers coordinate patient moves between settings.
“When we talk about, say, patients moving from hospitals to skilled nursing facilities or to home health or to home health from the skilled facility, there’s a lot that can get lost in translation,” said Nelson, who presented “Home Health and Skilled Nursing Facilities: Strategies to Elevate Care Coordination and Outcomes for All” as the opening session of the American Association of Post-Acute Care Nursing’s Quality Virtual Conference held last week.
The key is in communicating across settings and with patients and their families, as well as anticipating problems and establishing systems that predict them and head them off.
“Proactive care teams don’t wait until a patient calls them or a vendor calls them to share sensitive information,” Nelson added. “A proactive team is going to check in. They’re going to consistently engage with all team members to stay up to date on the patient’s care plan.”
In several sessions, the AAPACN event highlighted the need for nurses, clinicians and other team members to be involved across the continuum, both before and after a patient leaves a facility.
In this time when silos are out and accountability is more in than ever, Nelson advised providers to focus on communication, technology and care planning across shared electronic platforms — and on good old phone calls, too.
Those elements lead to a holistic approach that regulators, patients and their families expect today. Setting up patients for post-transition success very much begins in their first facility, Nelson said, noting that getting patients interested in their care can be a challenge when they’re at their worst physically.
But sharing health education resources via a patient portal or in-room technology is a good starting place. They also should be documenting all needs or concerns expressed by patients in a system home health providers will later have access to. That’s part of an effective and broad communication strategy Nelson endorsed.
Once providers have had conversations with patients and families to understand a patient’s social determinants of health and post-discharge support system, providers can also turn to specific tools to encourage engagement at home.
“If you can partner with some vendors who also have software that will help clinicians with, say, call handling to arrange meals, or DME or oxygen or any of the home health needs or vendor-related facility needs, that is huge in creating visibility and strong relationships in that care plan,” Nelson said.
She also stressed that partners, whether other providers on the continuum or vendors, need to be both reliable and innovative. No where is that more true than with the actual transition, or warm handoff.
“If you could really find a way that every layer of the handoff, transport, appointment handling, communication for provider and family could be seamless, in today’s world, right now, you are winning,” she said.
“Smooth care transitions are crucial in ensuring that continuity of care and a positive patient experience,” she said, noting that communication tools that help keep the experience positive also create a lasting “halo effect” that feeds directly into patient surveys. “These seamless transitions minimize the disruptions and really actually enhance patient safety. They contribute to effective care coordination by facilitating the transfer of vital information, ensuring the patients needs are met efficiently.”
