Lodi Memorial reviews each readmission with SNFs to learn what, if anything, could have been done to prevent it.
Transitions work, by nature, needs to be a collaboration between hospitals and the community services that support patients. When we had a readmission from a SNF, we reviewed each case based on certain criteria. We realized that our SNFs were also reviewing each case, but they were looking at other factors—we weren’t effectively collaborating to understand the cause for the readmission.
What We Tried
Most of the SNFs had a tool for reviewing readmissions. We looked at those forms and considered our own needs to create a standardized template that we could all use. We shared this with the SNFs at our quarterly meeting, obtained their feedback, and ultimately developed a single form that met our needs as well as theirs. Now, after every readmission, both parties complete the form, we set up a meeting or a conference call, and review the readmission and lessons learned.
These case reviews are very helpful—we always discover opportunities for improvement on both the hospital and SNF sides. We focus on discovering these opportunities together and improving together to avoid blame or a negative atmosphere. Currently, we designate staff to call the SNFs when a readmission occurs, to continue this process. These case reviews, combined with our monthly SNF work groups, have really helped to reduce our readmission rates. The readmission rates still vary and we continue to attempt further unnecessary readmission reduction.
Improved communication with SNFs
Increased comfort level discussing patient care and issues with SNFs
The monthly hospital/SNF work group meetings were essential to opening the doors for collaboration. Once we were all working together, it was possible to move to the next step of discussing specific cases with each SNF. The first few meetings allowed us to correct processes that were simpler and more easily corrected. We built the foundation to address the more difficult transition issues and this is a work in progress.