MAKING CARING CONNECTIONS:

CONTINUITY OF CARETRANSFER PROJECT

Management PresentationHospitalPresenter’s NameDate

OVERVIEW OF PROBLEM

Insufficient communication between hospitals and long term care communities during care transfers…

adversely affects the quality and continuity of care provided

contributes to adverse events and increased health care costs

HISTORY OF THE PROJECT

Best Practice Coalition identified the problems associated with transfers.

Appointed workgroup to find solutions. reviewed literature, standards and regulations conducted hospital and LTC surveys created a recommended transfer process, drafted model transfer

forms and guidelines Conducted a pilot with hospitals and LTC centers Revised forms and process based on pilot Best Practice Coalition recommended the

process and forms be adopted as a best practice

CONTINUITY OF CARE

BEST PRACTICE COALITION RECOMMENDATIONS

incorporate the recommended data elements into the forms used when transfers occur between LTC centers and hospitals

adopt the continuity of care transfer process

Use the forms consistently and follow the recommended process

All hospitals and LTC centers should do the following.

THE CONTINUITY OF CARE TRANSFER PROCESS

complete the appropriate transfer form fax the form to the receiving facility send a copy of the form and

recommended medical records with EMS or the family

call the receiving facility to give verbal report

All hospitals and LTC centers should do the following.

CASE DISCUSSIONS: PROBLEMS WE FACE WHEN

PATIENTS ARE TRANSFERRED

WHY SHOULD WE DO THIS? Improve quality, safety and continuity of

care during care transitions Improve handoff communication and

transfer of information Decrease medical errors Reduce the number of duplicated tests Decrease readmissions Increase patient satisfaction Reduce patient complaints and litigation Save staff time and frustration

WHY IS THIS IMPORTANT TO OUR HOSPITAL?

NQF has proposed improved care transitions from one setting to another as one of its 2009 priority goals.

CMS has made care transitions part of its 9th Scope of Work.

Included in two of the Joint Commission National Patient Safety Goals

New CMS Quality Measures focus on 30-day readmission rates.

Addresses many of the hospital-acquired conditions for which CMS proposes to withhold payment

HOW DO WE GET STARTED? Identify a project champion

and key players at your facility Establish goals and

benchmarks Review current forms and

processes Review project tools, forms

and resources Adopt or modify transfer forms

and guidelines Educate staff Do it! Review, evaluate and revise Celebrate and share successes

CONNECTING WITH LTC FACILITIES

Extend invitation to participate in a communitywide project

Ask them to identify a project champion and key players at their facilities

Host meetings to establish and promote transfer standards

Execute communitywide plan

MAKING CARING CONNECTIONS

…will make our residents and patients safer and make relationships between hospitals and nursing facilities stronger. Jeffrey A. Kerr, D.O., CMD