Lodi Memorial trained SNF staff on how to speak with resident families to prevent unnecessary readmissions.
Readmissions from SNFs can happen when a resident has a change in condition and the family requests the resident be sent back to the hospital. We identified two contributing factors. The first was that family members sometimes panicked when they received a call about a change in condition. These situations often happened at night or during off hours, and this was not necessarily an area of expertise for the SNF staff making the calls. We determined that how the information was presented to the family member could make a difference in how the family reacted. If the SNF staff called and reminded family that, “Your loved one came to us for comfort care. This is what’s happening, we can manage that and keep them comfortable here,” the family member might be agreeable to the original comfort care plan. If they are called with staff stating “There has been a change in condition, what do you want us to do?”, they may be more likely to respond in a panic and request that their family member be sent to the emergency room. The second factor involved with readmissions was that the patient may have had comfort care established at the hospital but those orders could not be transferred to the SNFs.
What We Tried
To address how SNF representatives call families when conditions worsen, Lodi Memorial social workers went out to each of the SNFs. We presented them with a variety of scenarios, asked how they would respond, addressed questions they had, and offered education regarding other ways to handle the situation. Most of the SNFs in the community were very open to this and helped us organize the sessions so that we could meet with both the day and night shift staff.
To address the comfort care patients, we asked SNFs what they would need to carry over comfort care orders from the hospital to their facility. In our case, the SNFs would accept a POLST (Physician Order for Life Sustaining Treatment) form. Now whenever a patient is getting discharged to a SNF and is at the comfort care level in the hospital, we make sure to complete a POLST form and send it over with the patient.
The combination of these two interventions plus regular meetings with the SNFs has reduced our SNF readmission rate.
Our efforts have also helped us establish stronger relationships with our local SNFs. We have multiple contacts at the facilities so communication flows more smoothly when patient issues or concerns arise. Due to the monthly meetings, a new community group of SNFs and Home Health Agencies has been initiated to further improve transition to the community.
We found that the SNFs in our community can have frequent turnover, so we continue to educate and communicate with them as much as possible.
Meeting with SNFs in the community has strengthened our unnecessary readmission prevention program. Transitions to SNFs can be very complex, and the collaboration identified areas where our hospital could improve transition preparation as well as what areas the SNFs could address. Some challenges were relatively easy to address once they were identified. We started with those and moved on from there. The effort continues.