By Melinda Young
EXECUTIVE SUMMARY
Standardized care protocols help improve care and reduce readmission rates for skilled nursing facility (SNF) patients, according to researchers.
- Hospital and SNF teams can work together to provide care for medically complex older adult patients.
- They identify conditions with high risk for readmissions and work with SNF teams to develop best practices.
- They identify delirium in hospitalized patients and ensure SNF staff are aware before the patient is transferred.
New research shows how standardized care protocols can improve care and reduce readmission rates for patients with chronic conditions in skilled nursing facilities (SNFs).1
Researchers studied 30-day rehospitalization rates of patients with congestive heart failure (CHF), COPD, and both conditions. The patients had been discharged to SNFs. They found improvements in readmission rates, especially for patients who had standardized care protocols in the SNFs.
“The ability for hospital teams to transition patients to skilled nursing facility teams can be enhanced through standardized protocols and through open channels of communication,” says Michele F. Bellantoni, MD, CMD, study co-author and an associate professor and clinical director in the division of geriatric medicine and gerontology at Johns Hopkins University School of Medicine.
One way is to bring both the hospital and SNF staff together to consider themselves one team for medically complex older adults. “The protocols facilitated communication, so it was the end product,” Bellantoni explains. “But what made the difference is we’re one team.”
Managing Medical Complexity
Nurse educators initially facilitated communication. Then, there were nurse coordinators taking on that role. “Now, it’s a nurse navigator for high-risk patients leaving our hospital and going into skilled nursing facilities,” Bellantoni says. “There’s a nurse navigator role for these complex patients.”
Some patients are so complex that they may not have lived long enough to be discharged to a SNF in the past. “We have to step up our game in managing medically complex older adults,” Bellantoni says. “Our [older] trauma patients have a geriatric medicine consult, and the discharge summary includes recommendations for managing these multiple medical conditions, managing medications, and managing delirium.”
Although hospitals and SNFs have different financial incentives, they are tied together in their care for patients and goals of positive outcomes. The relationship between the two is important for improving patient care during transitions. It also is important to communicate that partnership and its benefits to patients and their caregivers.
Hospital teams present the transition to a SNF in a positive way. “They’re saying, ‘We have the opportunity through partnership with SNF to enhance your care,’” Bellantoni says.
They tell patients the collaboration between the SNF and hospital teams will help ensure the patient does not face problems with their medication or symptoms so they will not have to return to the hospital after the SNF stay.
“The returns to hospital were due to delirium or because family members or patients weren’t comfortable that they were getting the best care at the SNF,” Bellantoni adds.
Protocol Unites Teams
The standardized care protocol, developed by both the hospital and SNF teams, brought both sides together. Teams that included the SNF medical director and leadership planned the care coordination improvement for six months.
“Our research paid for a registered nurse to go to these skilled nursing facilities, make routine rounds every week, and educate staff on the protocol,” Bellantoni explains. “The staff there would be comfortable saying to her, ‘I know we’re supposed to do this for CHF patients, but there are potential adverse events because we have these two medications.’”
Patients often leave the hospital on various medications that can increase the risk of new symptoms or problems. With improved communication and team-building, these issues are less likely to fall through the cracks. “A staff member may say, ‘We don’t need this medication now — can we stop it in the transition?’” Bellantoni says.
From a case management perspective, little changed because the teams handled the protocols.
“We identified conditions with high risk for readmissions. The hospital and skilled nursing facility teams came together in what we consider best practices in the care of these patients,” Bellantoni says.
Focus on Delirium
Staff changed the discharge summary to note whether patients experienced delirium. “When we send someone to a skilled nursing facility, [everyone] should know and recognize delirium,” Bellantoni notes.
Typically, patients with delirium were sent to SNFs without the hospital providing information to the SNF about that condition. This could lead to SNF staff not acting to help these patients with delirium. This is why it was important to include delirium in the discharge communication.
SNF staff need to help patients alleviate symptoms of delirium through tactics that could include opening their blinds in the morning and giving them activities during the day. “They need to look at unnecessary medications, particularly high doses of pain medications that may be sedating,” Bellantoni says. “It’s better to recognize patients with delirium before they leave the hospital.”
When delirium is identified, it must be reported to the SNF team so they know how to handle that patient appropriately. SNFs are better at managing delirium than hospitals, Bellantoni adds. “Hospitals don’t have activities for people, and physical therapy can’t give ongoing therapy in a hospital setting,” she explains. “Skilled nursing facilities have occupational therapists and other resources that are important in managing delirium.”
COVID-19 an Obstacle
One obstacle to forming effective teamwork with SNFs was the COVID-19 pandemic, which led to partnerships between hospitals and SNFs to deteriorate. “Skilled nursing facilities were places where there was too much COVID,” Bellantoni says.
In spring 2020, some hospitals did not have enough personal protective equipment (PPE), hospital beds, or staff to handle all the COVID-19 cases coming from SNFs and the community. This led to a breakdown in relationships between SNFs and hospitals. Johns Hopkins did what it could to maintain those partnerships.
“We deployed our disaster teams that were in place for hurricanes and floods to our local skilled nursing facilities,” Bellantoni says. “We had [fewer] hospitalizations from SNFs, and we had better care. Developing those relationships served us well during the pandemic.”
The disaster team plan was not just at one hospital. It was the result of health system leaders in Maryland learning from what happened in California early in the pandemic when there were incredibly high COVID-19 death rates in SNFs.
“Skilled nursing facilities don’t have as much private rooms, well-trained nursing staff, or PPEs as we did,” Bellantoni explains. “SNFs and assisted living facilities needed those partnerships.”
The disaster teams and partnerships helped the hospital as well. For example, Bellantoni received a call one Friday afternoon from someone at an assisted living facility. The person worried the facility did not have enough gowns and PPE for all their active COVID-19 cases. The facility’s solution seemed to be to call 911 and send everyone to the ED.
“I made a call to our chief executive. Within an hour, a van of PPE went to that skilled nursing facility,” Bellantoni says. “We didn’t get the whole assisted living [facility] in our ER.”
The cost of sharing PPE was worth the benefit of preventing overcrowding in the ED. “The point is showing that hospitals and skilled nursing facilities can partner even though their financial incentives are different,” Bellantoni notes. “We have a role in the continuum of care, and we value our partner and must make sure we communicate with them.”
This is the opportunity for providing a carrot — an incentive to work together, share data, and prevent hospital readmissions. One tactic is to bring both the hospital and SNF staff together to consider themselves one team for medically complex older adults.
“The protocols facilitated communication, so it was the end product,” Bellantoni explains. “But what made the difference is we’re one team.”
REFERENCE
- Hsiao YL, Bass EB, Wu AW, et al. Preventing avoidable rehospitalizations through standardizing management of chronic conditions in skilled nursing facilities. J Am Med Dir Assoc 2023;S1525-8610(23)00720-X.
New research shows how standardized care protocols can improve care and reduce readmission rates for patients with chronic conditions in skilled nursing facilities.
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