To improve care transitions for individuals with cognitive impairments, Dominican Hospital developed a support care handoff tool.
When dementia-related behavioral needs are prominent during hospital care, post-acute services can be complex to arrange. Management of dementia and the related behavioral and functional needs often lead to barriers for safe discharge and increase the risk for re-hospitalization. Effective hand-offs offer a critical opportunity to communicate the level of cognitive impairment as well as risk factors and identified interventions, which can lead to improved outcomes and patient care.
Location- Santa Cruz, CA.
Type- Largest safety net provider in Santa Cruz County.
Number of Beds- 179 Acute (including 14 NICU) beds and 20 Acute Rehabilitative Unit (ARU) beds.
Payer Mix- 25.4 percent commercial, 47.7 percent Medicare and 22.7 percent Medicaid.
Population Served- A large rural area comprised of 56 percent white, 35 percent Hispanic, 4 percent Asian and 5 percent other ethnicities.
Dignity Health Dominican Hospital has been providing quality-focused comprehensive health care to the needs of California’s Monterey Bay region for 75 years.
What We Tried
In an effort to support successful transitions to the next level of care for persons with a cognitive impairment, Dominican Hospital developed a support care handoff tool. This tool addressed the hospitalized patient’s cognitive care needs and functional status and identifies successful interventions and strategies that can be incorporated into the patient’s daily hospital routine. The tool is intended to be a working document with input from occupational, physical and speech therapists, nurses and family on what activities calm or stimulate the patient, such as use of a heavy blanket, lying down, music playing, pictures from home, coffee and touch. The handoff tool also identifies how the patient takes medication, the John Hopkins fall risk score, history of wandering, nutrition, toileting and how best to communicate to the patient (e.g., simple words, provide cues, written information). When the patient is ready to be transitioned to a skilled nursing facility (SNF), case management faxes the completed form to the Driftwood Healthcare Center, the pilot SNF identified to test this approach.
Dominican Hospital’s acute care therapy supervisor met with the occupational therapists at Driftwood Healthcare Center to review and add input to the support care handoff tool. The supervisor conducted a training and educational seminar for Driftwood staff, which included their medical director, nurses, occupational therapists and certified nursing assistant champions. The topics included identification of mild vs major neuro-cognitive impairment, application of interventions and a review of the use of the support care handoff tool.
The support care handoff tool is completed for all Dominican patients identified with cognitive impairment. It is posted on the patient’s white board, and nurses, therapists and family can add to the form. For patients transitioning to Driftwood Healthcare Center only, the handoff tool is faxed prior to the patient’s arrival. All other identified patients with cognitive impairment, who transitioned to other SNF’s, do not receive the handoff tool.
Driftwood’s nursing personnel have reported increased satisfaction in their increased ability to settle patients into their new environment with decreased behavioral outbursts.
The pilot’s goal is to address whether the identification of personalized interventions reduce behavioral disturbances in the post-acute setting and, consequently, reduce inappropriate use of antipsychotics and sedative medications for disturbances and reduce readmissions. Currently we are collecting readmission data from all SNF’s transitions. Using a case study model to identify root causes, the Dominican team will analyze comparisons between Driftwood Healthcare Center using the handoff tool and other skilled nursing facilities that did not have the handoff tool. The Dominican team will review questions regarding the ability of the staff to “settle the patient” upon arrival and how long that took, the number and type of behavioral disturbances and use of antipsychotics and sedatives.
It was important to include Driftwood Healthcare Center personnel in the development of the handoff tool. This allowed for a standardizing of its use across the continuum. Also, support from acute hospital nursing leadership helped frame the importance of this tool and use by all nursing staff.