Improving Communication at Transition from NH to ED

1. Improving Communication at Transition from NH to ED Suzanne Gillespie, MD RD Division of Geriatrics/Aging March 6, 2009 2008 AMDA Foundation/Pfizer Quality Improvement Award: One Year Update

2. Background • University of Rochester Div of Geriatrics • Primary care for > 3,000 LTC residents • 34 NH and ALF facilities • Monroe Community Hospital (MCH) • 566-bed county-owned NH with an academic medical staff • Frequently send and receive patients to/from a variety of other medical settings in the region. • Routine • Emergently

3. Transitions of Care from NH • Frequently involve multiple people • Patient, Families, Nurses, SW, EMS, Doctors…. • LTC (& EM providers) expressing frustrations about care communication on a daily basis. Grant Award: opportunity to translate frustrations into QI

4. “LTC Quality Council” • Focused on improving transitional care between organizations • Bi-Monthly Meetings • Representatives • Medical Center, NH/ALF, home care • Emergency Medicine & Geriatric Medicine • Nursing, social work, physicians • Quality Management Leaders

5. NH to ED Transitions: Perceptions • ED and LTC teams expressed different perceptions of transitions of care • “doing a great job” “issues on a daily basis” • “incomplete” “inaccurate” “disorganized” “variable” • Variability in what each of the homes provided • Variability in how providers define good communication • Neither sending nor receiving caregivers know what to expect when a resident is transferred to the ED.

6. Survey of ED and LTC Providers Respondents, n=155 • Physicians (23%; n=36) • NPs/PAs (14%; n=21) • Nursing (63%; n=98) • Comparable #LTC and ED respondents • Experience in their field • 41% reported >11 yr • Response rate = 32%

7. Impressions of Nursing Home Care Transitions Percent who agree/disagree with the following statements… Strongly Disagree Strongly agree Somewhat agree Neutral Somewhat disagree Important information is lost during transitions of care between NHs & EDs There is good communication between EDs & NHs in this community

8. how often you believe the following occurs when a NH resident is transferred TO the ED for care?(1=NEVER, 7=ALWAYS)p<.01 ALWAYS NEVER *

9. how often you believe the following occurs when a NH resident is transferred TO the ED for care?(1=NEVER, 7=ALWAYS) always never

10. How often you believe the following should occur, when a NH resident is transferredFROM the NH TO the ED,

11. a verbal communication at my position/level should occur (doctor/NP/PA)

12. a verbal communication at my position/level should occur (nursing)

13. Transfer Form • Focus group • Feedback • Survey input • Pilot • Revisions

15. COPIES TO SEND WITH RESIDENT:

16. Pilot • 45 residents’ transitions audited • 17 (38%) nothing- no information • 16 (36%) used an old form • 12 (27%) new form • 100% code status • 100% reason sent; often with extra detail • 100% usual mental state • 50% contact information

17. Pilot Challenges • Change • Xeroxing • Option to use something else… Revisions • Hospitalists call…. • Acute Quality Measures • (Smoking, Vaccination, Wound status) • Streamline data included Process • Re-engage staff • Units pre-customize data • Re-assessment

18. Reflections • The improvement • is not just the form….it is the process • Most valuable aspect of this QI initiative • Introduction of joint accountability for transitions • Establishing a feedback mechanism

19. Next Steps • Reassess after revisions • Implement at other local facilities • Regional standard • Define the role of verbal communication • Improvements in Ed to NH transitions