The Problem
Following inpatient hospitalization, many older patients require post-acute short term rehabilitation with skilled nursing facilities (SNFs) in order to regain their functional independence. This transition from hospital to post-acute care marks a pivotal shift in patient care with high potential for errors, readmission to the hospital, and mortality.1 Discharge to SNF is a strong predictor of 30-day rehospitalization, and these readmissions are associated with an increased mortality rate even after adjusting for age, comorbidities, and prior health care utilization.1 In 2017, the SNF 30-Day Observed All-Cause Readmission Measure was 18.87%.2 Prior studies have indicated that 31%-67% of 30-day readmissions remain preventable.3,4 Poor communication of critical information during the transition from hospital to SNF is a commonly cited reason for preventable readmissions.5
The Solution
Following the work of the HOPE workgroup and SNF Collaborative, our intervention sought to improve the hospital to SNF transition through multidisciplinary videoconferencing.
Project Objectives:
Overarching goals for the project included:
- Patient harm reduction
- Readmission reduction
- Transitional care improvement
- Identification of opportunities for health system improvements
- Improvement in patient connection to existing health system resources (e.g., DukeWell care management, palliative care, and timely PCP follow-up)
Solution and Outcomes:
In July 2019, we launched a weekly post-discharge telehealth video conference to facilitate multidisciplinary review of patients hospitalized at DUH or DRH and recently discharged to one of our partner SNFs. These conferences allow for a brief discussion of each patient, focusing on transitional care pillars such as medication reconciliation, disease optimization, follow-up plans, and advanced care planning. Our multidisciplinary team consisted of a hospital medicine lead clinician, pharmacists from DUH and DRH, a geriatrics fellow, the HOPE APRN, and a case manager.
Between July 1st and December 31st, 2019, 24 telehealth conferences were held with a total of 3 SNFs to discuss 229 transitions among 220 distinct patients. Sixty-four percent of our population was hospitalized at DUH, and 36% at DRH. Seventy-six percent of patients were on general medicine service lines, while approximately half of patients reviewed at DUH were from non-general medicine services. We have observed a reduction in readmission rates as compared to patients discharged to the pilot SNFs during the same timeframe of the prior year, 14.29% in 2019 vs 22.3% in 2018. Other clinical metrics observed included a slight decrease in 30-day mortality, 6.19% in 2019 vs 7.07% in 2018, and a somewhat increased 30-day ED return rate, 10.96% in 2019 vs 7.94% in 2018. In addition, we have descriptively evaluated errors identified in the care transition during the videoconferences. Forty-four percent of patients reviewed had at least one error intervened on, with 54% of errors involving communication, 43% involving medication, and 3% involving DME.
*could add in medication-related data as well or types of recommendations made once RedCap is updated*
Next Steps:
In addition to continuing the established telehealth conferences with our current SNF partners, we propose expanding the program to additional partner skilled nursing facilities. We also envision further partnerships with PHMO and the potential use of this telehealth program to support other health system initiatives such as the 3-day waiver program and bundled payment models.d
