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“There’s No Place Like Home”: Creating a Safe, Individualized, Transitional Care Pathway After a Skilled Nursing Facility Stay


Yvonne Rice, PharmD; Hannah Austin, MBA; Preston Peterson, MD


Abstracts from the Kaiser Permanente 2018 National Quality Conference

From Northwest

Background: Care transitions from skilled nursing facilities (SNF) to home is a known clinical quality gap for medication reconciliation and safe, coordinated follow-up care. Kaiser Permanente Northwest 2016 baseline performance of Hospital 30-day All Cause Readmission Rate for this population is higher than expected at 21% and indicates an opportunity for improvement. The objective is to improve safe transitions of care from SNF, reduce avoidable hospital readmissions, and prevent serious medication discrepancies causing an adverse drug event.
Methods: The target population is patients from contracted SNFs in the East Service Area who discharge to home or to a homelike facility. The intervention is the execution of a SNF Transition Bundle, which includes risk stratification, a transition hotline number, standardized discharge summary, pharmacist medication reconciliation, a transition nurse (RN) follow-up call or mobile health partner home visit, and practitioner follow-up appointment within 7 days. The target population was compared with patients discharged from contracted SNFs outside the East Service Area. The success measures are decreased 30-day hospital readmission rate, decreased harmful medication discrepancies and/or errors, and improved care experience with safer transitions.
Results: Outcomes and performance at Friendship SNF (baseline through September 2017): Hospital 30-day readmission rate decreased from 22.6% to 17.3% after Transition Bundle elements were implemented from January to year end. Serious medication errors at discharge decreased from 42% to 5%. Medication Reconciliation Post-discharge (Centers for Medicare and Medicaid Services 5-star) increased from 14% to 80% (rolling 12-month rate). East Service Area SNF Transition Bundle performance results from first 6 months (June-Nov): Pharmacist medication reconciliation for 91% of patients; follow-up contact (RN phone call or mobile health partner home visit) for 81% of patients; follow-up appointment within 7 days for 47% of high-risk patients.
Discussion: Medication issues are complex and confusing for patients after SNF transitions of care and require dedicated resources to optimize reconciliation in the home. Coordination of care is improved with transition RN calls including family education, assistance with follow-up appointment, transportation, financial assistance, coordination with multiple teams, and action on acute symptoms. Contracted SNFs can be influenced to support safer medication processes, discharge processes, and patient education. Workflow improvement is needed to reduce duplication and rework, and build efficiency. The next step is to spread the SNF Transition Bundle model of care to all contracted SNFs in the Region.

Abstracts from the Kaiser Permanente 2018 National Quality Conference


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