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UCSF sends partner SNFs an email with patient-specific concerns and contact information when transferring patients to them.
As a teaching hospital, our care teams change frequently. We may readmit a patient 3 times in a month and each time they can end up on a different floor with a different team and a different case manager. This made it very hard for outpatient providers to know whom to contact if they had a question or concern about a patient. This could result in care decisions that conflicted with a patient’s previous care—or patients simply being sent back to the hospital.
On the flip side, turnover at SNFs is also very high and it was important for us to have a direct line of communication with someone.
University of California Medical Center is a teaching hospital in San Francisco, CA. It has 660 beds and serves a diverse population with varying educational levels and languages spoken (including Cantonese, Mandarin, Russian, and Spanish). It is also an advanced heart failure and transplant hospital with patients traveling from across California for their health care. Their transitions program began in 2008 and is influenced by IHI’s Transforming Care at the Bedside.
We partnered with the 3-4 SNFs in our community that most of our patients went to. We sent them an email when a patient was discharged to let them know the patient was enrolled in our Heart Failure program. Although patients get discharged to SNFs with a transfer packet, our emails offer a way to share feedback on risk assessment, teach back, and other concerns or findings about the patient. The email communication to the SNFs also offers contact information, including the patient’ primary MD, the discharging MD team, and our contact information in case of any follow up questions or concerns. Since we were a constant part of the patient’s care team, even across hospital visits, we could answer questions or redirect them to the appropriate people. We also asked them to let us know when the patient was getting discharged home so that we could follow up with them again if necessary.
The email really opened up a dialog with the SNFs. It not only made it easier for SNFs to answer care questions quickly, it also made them feel like a valued member of the team. We recognized that they were an important part of the equation and would support them in any way we could to provide the patient with the best care possible. The email further improved the care of the patient and communication between hospital and SNF. This email was critical in the transition of care and it was one more hand over – beyond nurse to nurse – to the case managers, dietitian, and administration of the SNF letting them know this patient is part of our program.
Additional benefits included the collaboration and suggestions from the SNF about what information would be most helpful in an email—MD contact information, dry weight, if goals of care discussions had occurred, previous home care agency used or recommended, and more.
We continuously revise the template email to add information based on the needs of the SNF staff and the best transition for the patient.
We used our hospital’s secure messaging system to reach out to the SNFs because we needed to include private information about the patient’s health and care.
Program Challenges: Coordinating with Outpatient Care
Topics: After-hospital care
Collaborator (Non-Members): Eileen Brinker
Organization Name: UCSF Parnassus
Location: 500 Parnassus Avenue, San Francisco, CA, United States
Organization Type: Hospital