Cheryl Boldt, RN, LNHA

Problems can arise when “Patients” are admitted to long term care skilled nursing facilities from an Acute Hospital if they are told they only need “a few more days” of rehab before they can go home. A “few more days” is vague, but may help convince the customer to agree with the transfer to a Rehab Unit in a skilled nursing facility. Once the patient is admitted to the facility, they immediately start asking multiple staff members, “When can I go home?” If they do not get a consistent response, the patient and family begin to make their own plans to go home.

A Team-Based Safe Transition Planning Conference allows the Post Acute Trans-Disciplinary Team of Experts to dialogue with the patient/family as a Team, very soon after admission, usually within 48-72 hours. The purpose of the STP is to establish and communicate the Safe Transition Date and Destination with the patient and their family to lay the foundation for a safe transition. This process has multiple benefits for the patient/family, strategic health and housing partners, and for the facility team. This proactive effort results in positive outcomes, including preventing Readmission to the Hospital, Emergency Department Transfers, and improved customer satisfaction. The Safe Transition Planning process must be team-based, cohesive, and not fragmented. Communication regarding the plan must be shared clearly throughout the patient’s stay with all stakeholders. An early exit and/or poorly orchestrated transition to a Lesser Level of Care poses risks for the patient, facility, referring hospital, and facility strategic partners.

It will help your team’s efficiency if you set aside/protect 30 minute timeframes daily that are at least equal to the number of admissions you average weekly. This supports the ability of all team members to be in attendance at the STP conference. Typically, Monday and Tuesday require more timeframes related to a higher volume of admissions on Friday and Saturday. The Administrator holds the team members accountable for their attendance. Please refer any questions regarding documenting skilled therapy minutes for a therapist’s participation in the STP to your Therapy Provider.

The goal of the Safe Transition Planning Conference is to:

Achieve a smooth and safe transition
Determine the right location
Determine the right length of stay
Assess the patient’s individual situation, condition and payer
Prevent readmission to the hospital and emergency department visits

The person responsible for the coordination of Safe Transition Planning is generally the facilitator of this process and maintains the Master Transition Planning Calendar to support an even flow of transitions to and from the facility. Preferably, your facility has a dedicated Rehab/Transitional Care Unit. An even flow of customers coming and going supports a good customer experience. Early Safe Transition Planning minimizes frustration related to the duplication of questions asked and responses given by all parties. The following team members are customarily present at the STP Conference.

Transition Coordinator/Social Worker
Nurse assigned to the patient
CNA
MDS Coordinator / Case Manager for Managed Care
Therapist
Dietitian or Dietary Manager
Recreation/Activities
Business Office Manager

Home Health Care Representatives, or an ALF/IL Representative if the patient resides with them, can also be in attendance to get early leads for their role in Safe Transition Planning.

Establish time slots for STP Conferences based on the volume and patterns of admission flow. STP should become a habit with the necessary time routinely protected by all team members. The average STP Conference takes 25 minutes. Each team member needs to listen to the patient, family and other team members, share their expert insight specific to each patient’s circumstance and only ask questions that are needed to assist the team in establishing the Safe Transition Date and Location.

Identify and prioritize patients who need their STP Conference sooner related to a high likelihood they will exit early if there is not a clear Safe Transition Plan and the rationale for that Plan is not shared shortly after admission. To the extent possible, arrange to have the family present in person, by speaker-phone, or videoconference. Please note: The most efficient practice is for the team to go to the patient’s room. Obtain patient consent if a roommate is present.

Conduct the STP Conference in a positive, non-intimidating manner that is conducive to team discussion and decision making. Share information and recommendations compassionately, honestly, and firmly when the patient’s safety and health needs are being identified. Watch your body language, and have a chair setting next to the patient so the team members can seat themselves next to the patient when needed during interaction.

The following is a brief description of the focus of each IDT Member during the STP:

Transition Coordinator/Social Worker
Introduce the Patient/Family and give a brief overview of the their recent hospitalization and their history, current living arrangements, family support, home services they have received prior to hospitalization, a brief summary of other hospitalizations, a loss the patient has experienced that could affect motivation, emotional and psychosocial status. Ask the patient to share something they would like the team to know to personalize the interaction.

Licensed Nurse
Review the patient’s clinical status/skilled nursing assessment, skilled nursing interventions, patient’s functional status for nursing, begin to educate as appropriate about risk for ED visit or readmission to hospital and the facility’s capabilities to prevent, importance of early recognition of signs of illness. In addition, address the action to be taken when early warning signs of illness are noted, as well as clinical and functional barriers that need to be overcome prior to safely leaving the Transitional Care/Rehab setting.

Recreation/Activities
Address the meaningful activities of life the patient can no longer do because of their illness, injury or decline in ability. Efforts to help the patient regain these skills can often be appropriately included in the treatment plan.

Dietary
Share barriers to a Safe Transition related to nutritional status. This may include, but is not limited to, significant weight loss or gain, interventions for wound healing, labs that are out of parameter, meal intake, compliance with medically necessary diet and risk for dehydration.

Business Office
Discussion regarding co-insurance/co-pay/private pay portion. This would include the ability to set up a reasonable monthly payment plan for charges that will be the patient’s responsibility. Some patients will not adhere to the recommended length of stay for a safe transition because of the private portion that may be billed. This would also be the time to mention we can assist with Medicaid application if this is indicated.

Therapy
Listen to the information shared by all team members and share the patient’s current level of function based upon therapy involvement thus far and recommendations on the level of function that needs to be achieved for a safe transition to a lesser level of care. Therapy Services are a large component of, but not the only driver of, length of stay. The therapist explains how a therapy schedule is established based on the patient’s preferences, the importance of compliance with the therapy schedule to achieve functional goals, and the strategies we employ to assure patients can participate in therapy to their maximum potential. The therapist usually recommends the family be aware of the therapy schedule and asks visitors to avoid coming during the day when the patient will be in therapy, resting between therapy sessions, or dining. The therapist will also discuss options for family member participation or presence at therapy sessions.

The Team
The Team then makes a recommendation for the patient’s Safe Transition Date and Destination. The Team’s recommendation often differs from what the patient/family had in mind or were told in the hospital. We also find that transitions occur smoothly on Tuesdays, Wednesdays, and Thursdays without bounce backs, but are not as successful on Friday, Saturday and Sunday. Safe Transitions are affected by provider availability, home health starts and available pharmacy services in some locations, and families who are not as available as they thought they would be. This all should be considered when establishing the Safe Transition Date.

The Team’s recommended Safe Transition Date and Destination is placed on the Facility Master Transition Planning Calendar and on the dry-erase board in the patient’s/resident’s room with the patient’s documented consent. This means the STP (Safe Transition Plan) information is in view of the patient and family, and it assures that all facility staff/team members have knowledge of and can support the STP. Explain that if the patient does better than expected, the team will communicate with them regarding an earlier transition date. If the patient has complications, the team will communicate with them (and their payor source) regarding the need for a later transition date.

A patient-specific Safe Transition Checklist should be developed and provided to the patient and family and updated as the patient achieves the established goals, and as barriers to a safe transition are removed. While the patient certainly has the right to disagree with and not follow the recommendation, the IDT has a responsibility to educate and continue to work with the patient and family on a Safe Transition Plan. The Safe Transition Planning Team has a responsibility to meet all documentation and communication requirements established by the Patient’s Payor Source(s), including Bundled Payment Programs, and to work with the Payor/Payment Entity/Navigator/Case Manager to achieve a Safe Transition for our Customer.

Share the Safe Transition Plan with any physician/physician extender who sees the patient/resident while they are in the SNF or SNF TCU/Rehab Unit. Please note, any post-hospital follow up MD appointment is a critical time to clearly share this information, or the patient may return from that appointment with orders for discharge home today on current meds. It is helpful to have a single sheet of brightly colored paper placed at the top of any documents sent to an MD appointment with the words;

“To assure a Safe Transition for (name of patient/resident) and to prevent re-hospitalization, the Safe Transition Date for (name of patient/resident) is ______ and the Safe Transition Destination is ______. Please do not alter this plan without first contacting the Transition Coordinator (name ______) at (number ______).” 

If your facility has a SNFist who works with the team, this Physician and his/her Physician Extenders and/or the Patient’s own Physician/Extenders are certainly welcome to join the team at the STP Conference and work with the Team to support the Plan.

Please eliminate the term discharge from your vocabulary. Ask therapists and all team members not to use the term discharge because many patients interpret it as “I can go home now.” This is evidenced by the number of patients who call their family and say, “Come pick me up, I am discharged” when a therapist shares they are discharging them from their case load.

A very high percentage of patients who are admitted to a SNF after hospitalization are elderly, frail, have co-existing disease processes, poly-pharmacy, and a history of recurring hospitalizations and/or emergency department visits. Patients without complications need a few days, and highly complicated patients need much longer.

Multiple Healthcare Settings and Providers are being monitored for Readmissions to the Hospitals and visits to the Emergency Department. Penalties have occurred for Acute Hospitals and Value-Based Purchasing Opportunities are at stake for Healthcare Providers including SNF’s and Home Care. CMS’s 5-STAR Rating Quality Measures reflect your success at preventing return to hospital and emergency department visits. The SNF needs great systems to prevent ED visits and Readmission to the Hospital. It is our responsibility to assist the patient/resident in a safe transition to a location with the support needed that will indeed prevent and minimize the need for ED visits or re-hospitalization. Going to the emergency department or being readmitted to the hospital is not pleasant for the patient, or the family, and is also very costly.

If a patient leaves the SNF while they are still in the 30-day post-hospitalization timeframe and goes to the ED, or is Readmitted to the Hospital, this is tracked back to the SNF.

There are many factors that affect compliance with, or adherence to, the STP recommendation. At your Daily Huddle, you will have the opportunity to revise the date and destination with any variances to progress and communicate/gain agreement with the new Safe Transition Date and Destination accordingly to all stakeholders.

Of critical importance are the Strategic Partnerships you develop with other Healthcare entities such as Home Health, Hospice, Palliative Care Providers, Assisted Living, other SNFs, and Vendors such as Pharmacy, Infusion Therapy, Durable Medical Equipment, and Technology for Safety at Home. Align yourself with those who have demonstrated success with Safe Transitions of Care and preventing readmission to the hospital, as well as emergency department visits.

Safe Transitions are a Win-Win!