Timely Transitions to Skilled Nursing Facilities Amir Barzin DO, MS, Assistant Professor, Director Family Medicine Inpatient Service; Joan Crowson, RN, MSN, CCM, Assistant Director Care Management; Maureen Dale, MD, Assistant Clinical Professor; John Downs, MD, MBA, Senior Medical Director of Care Management and Patient Logistics; Katie Flanagan MSW, LCSW, ACM, Assistant Director Care Management; Angela Ford, MSW, LCSW, Operations Manager; Jacci Harden MHA, MBA, RN, NE-BC, VP & Associate CNO; David Hemsey MD, Associate Professor of Medicine, Chief Division of Hospital Medicine; LaKeshia Holley, RN, MHA, ACM, Manager Care Management; Kimberly Mihaliak, MBA, Quality Analyst; Vanessa Neustrom, MSW, LCSW, ACM; Manager Care Management; Jamie Pope, BSW, MHA, Manager Operations; Ali aheed Quadri, MBA Quality Analyst; Liz Spero, MHA, RN, CCM, CPDAM, Manager Care Management; Amy Stuckey, MSW; Tonya Thompson, MSW, LCSW, ACM, Manager Care Management; Marie Watras, RN, MBA, Administrative Director of Care Management & Patient Logistics
Situation It is optimal for patients to present to SNFs earlier in the work day when providers are available for collaboration. Overall operations, patient wait times, and length of stay are negatively impacted by late-day discharges creating a throughput bottleneck. Patients with acute care needs waiting for admission receive care more promptly when patients are transitioned earlier in the day. Between 9/1/2016 and 9/30/2017, the UNC Medical Center and Hillsborough campus discharged 3,065 patients to skilled nursing facilities (SNFs) for post-acute care. In reviewing the time of discharge for these patients, we noted that a large majority(63%) discharged at or later than 2pm. The project team hypothesized that earlier discharges can be facilitated by addressing multifactorial barriers: o Lack of ambulance availability o Culture of late in the day discharges o Lack of understanding of patient care/throughput impact o Discharge summaries not completed by provider earlier in the day o Pending insurance authorizations o SNF Bed offers and discharge occurring on the same day o Patient/Family choice between available bed offers
Key Observations
Key Changes Care Management department partnered with key providers, nursing leadership and local ambulance companies.
Developing and maintaining strong relationships with ambulance transportation providers was key in decreasing transition time and improving overall project outcome Delay Tracking Sheet
The UNC project team created a tracking process to illustrate delays in prompt transitions to skilled nursing facilities.
The root-cause analysis and collecting data on transitions of care was helpful in identifying process improvement opportunities and in engaging stakeholders
The UNC project team requested ambulance companies stage trucks between 11am-2pm to meet anticipated volumes based on historical data.
Focusing the scope of the project only to look at transition times to skilled nursing facilities allowed for more targeted interventions and improved overall outcomes
The UNC project team developed a tool to educate providers, nursing and care management staff on project rationale and goals.
Focusing on patient safety and patient experience enhanced staff engagement Collecting data on transition delays, transition times, time of signed provider discharge orders and discharge summaries helped highlight and educate stakeholders on inaccurate preconceived notions about opportunities for earlier transitions
The UNC project team developed an ongoing process for data review and performance improvement within participating departments.
Findings & Outcomes To date, 2,386 patients have been transitioned to skilled nursing facilities (between 01/08/2018-1/22/2019)
Aim
Providers wrote 87% of discharge orders and signed 86% of patient discharge summaries by 1pm The mode discharge time decreased from the 2:30 pm to 1:00 pm
Engage key stakeholders (Ambulance transportation providers, care management assistants, care managers/social workers, discharging providers and nursing staff)
Maintain strong relationships and open communication with ambulance transportation providers
The average discharge time decreased by 26 minutes The percentage of patient’s discharged to skilled nursing facilities by 2pm increased from 37% to 64%
Reduce wait times for patients awaiting ambulance transport Meet 1pm discharge target by scheduling transportation one day in advance of anticipated transition date Improve overall operations in transitioning patients to skilled nursing facilities.
There was no significant time difference in transitions of care between Medicare Advantage plans requiring precertification versus traditional Medicare plans not requiring precertification
Signed Discharge Order and Discharge Summary for Patients Transitioning to Skilled Nursing Facilities by Hour of Day
Next Steps to Improve Transitions of Care
Discharges to Skilled Nursing Facilities by Hour of Day
Ongoing data analysis to evaluate the broader scope impact on overall length of stay and readmission rates Continue data collection to further enhance interventions related to timely transitions Evaluate data to identify themes and trends in service line specific barriers Ongoing education on the benefits of earlier transition times for this high-risk patient population
Breakdown barriers to providing quality healthcare: o Create patient-centered transitions of care o Increase knowledge of the issue and opportunities to positively impact care o Create effective methods for data collection o Improve relationships with transportation providers and SNFs
Evaluate impact of earlier discharge times on patient and family satisfaction
Background Data
Acknowledgements
Volume of Discharge for Top 6 Payors by Day of Week
Discharge to Skilled Nursing Facilities by Payor by Hour of Day
Ambulance Companies Northstate First Choice Jan-care LifeStar
UNC Collaborators: Care Management Nursing Medical staff