The University of Wisconsin Hospitals and Clinics created a SNF-Acute Care coalition to address challenges of transitioning between settings.
Anecdotal evidence has revealed issues related to inadequate written and verbal communication between settings along with a lack of standardized tools and processes. The Skilled Nursing Facility-Acute Care coalition was created as a venue to enable hospital and skilled nursing facility (SNF) staff to personally meet and discuss issues both sides were facing as SNF residents were being transitioned between settings.
Location- Madison, WI.
Type- Academic medical center.
Number of Beds- 648 beds.
Setting- Urban; however, patients are referred regionally as well.
Payer Mix- For the 2015 fiscal year (from July 2014 to June 2015), our payer mix was the following: 53 percent commerical/capitate programs, 34 percent Medicare, 10 percent Medicaid, and 3 percent other government programs.
Population Served- Urban Madison, WI and patients from surrounding regions.
University Hospital is a regional referral center that is home to a Level One adult and pediatric trauma center, burn center, stroke center, organ transplant programs, and the UW Carbone Cancer Center.
What We Tried
The goal of the coalition is to address barriers related to safely transitioning SNF residents to and from acute care settings and to collaboratively rectify the issues identified. Our first step in organizing the SNF coalition was emailing invitations to area SNF leaders to attend monthly coalition meetings hosted by the hospital. We requested SNF staff attendees include directors of nursing, administrators, intake staff, direct care nursing staff and social work. The coalition meets the second Wednesday of each month from 8:30 a.m. – 10:30a.m. The meeting is led by the transitional care director and the program specialist. Twenty nine SNFs have maintained consistent membership and participation. Meeting agendas typically include: welcome/introduction, focused discussions surrounding barriers and solutions, utilization of standardized bi-directional written tools and verbal communication processes and a 15-30 minute clinical educational session. UWHC departmental leadership and staff including coordinated care, pharmacy, nutrition, wound care, and therapy services attend meetings to address applicable issues/topics. Educational session topics are provided upon request of the SNF attendees and have included: wound/skin care, medication safety, fall prevention, respiratory care, palliative care, advanced directives and end-of-life care planning.
The coalition meeting format allows for a safe environment to discuss issues and collaboratively arrive at solutions which are acceptable to both settings. Attendees have expressed an appreciation for the opportunity to meet each other in person and the ability to gain a greater understanding of each other’s settings, staffing matrices and admission/discharge processes. Outputs of coalition efforts include a revised hospital SNF discharge order set and transfer packet and development of standardized Emergency Department-SNF bi-directional transfer tools and verbal communication. Ongoing quality improvement processes include: shared (blinded) facility specific readmission rate reports, facility-led root-cause analysis of complicated transitions/readmissions, and focused discussion of new tools and processes being piloted by coalition members.
- Coalition leaders must set a no-fault, safe environment for open dialog to occur.
- SNF attendees should identify internal change agents who have the authority to make necessary changes. Ideally these individuals should be clinical and not administrative.
- Meeting agenda items and education topics should be based on expressed need of attendees.
- Include hospital departmental leadership/staff at the meetings ad hoc to address barriers and identify solutions during the meetings.
- Be patient and remember that it is very difficult to bring about change in facilities where you have no control. Engaged SNF stakeholders will make the changes happen.
- Reassurance, encouragement and praise for small steps goes a long way to sustaining change.