Discharges and Readmissions: Advancing Effective Coordination of Care

presented by Colleen Morley, DNP, RN, CCM, CMAC, CMCN, ACM-RN and Nancy Skinner, RN, CCM, CMGT-RN, ACM-RN, CMCN, FCM

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Disclosure Statement:

Financial: Colleen Morley receives compensation from MedBridge for this course. There is no financial interest beyond the production of this course.

Nonfinancial: Colleen Morley has no competing nonfinancial interests or relationships with regard to the content presented in this course.

Financial: Nancy Skinner receives compensation from MedBridge for this course. She is a consultant/educator at Encompass. There is no financial interest beyond the production of this course.

Nonfinancial: Nancy Skinner has no competing nonfinancial interests or relationships with regard to the content presented in this course.

Satisfactory completion requirements: All disciplines must complete learning assessments to be awarded credit, no minimum score required unless otherwise specified within the course.

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Video Runtime: 61 Minutes; Learning Assessment Time: 33 Minutes

Transitioning from acute care to post-acute care may contribute to the development of negative healthcare outcomes. Research indicates that as many as 20 percent of patients experience adverse events within three weeks of discharge, nearly three-quarters of which could have been prevented or ameliorated. Members of the transdisciplinary receiving team within post-acute environments of care may not be aware of all previously provided interventions and diagnostic evaluations performed during hospitalizations. With as many as 40 percent of patients discharged with test results pending and plans for further workups not communicated appropriately, patients may face a discoordination of care that often compromises the ability to promote the achievement of desired outcomes.

Effective and efficient care coordination across the discharge and admission process is vital to advancing patient safety, promoting the achievement of desired patient outcomes, and maximizing reimbursement for provided services. This course will offer an overview of care coordination and transitional care teams and processes that advance an ability to reduce the rate of potentially preventable emergency department visits and readmissions while supporting initiatives to return the patient to their community. This course is applicable to physical therapists, occupational therapists, speech-language pathologists, nurses, social workers, and case managers.

Meet Your Instructors

Colleen Morley, DNP, RN, CCM, CMAC, CMCN, ACM-RN

Dr. Colleen Morley has held positions in acute care as director of case management at several acute care facilities and managed care entities in Illinois, overseeing utilization review, case management, and social services for more than 12 years and piloting quality improvement initiatives focused on readmission reduction, care coordination through better communication, and population health…

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Nancy Skinner, RN, CCM, CMGT-RN, ACM-RN, CMCN, FCM

Nancy has, for the past 30 years, served as a case manager, director of case management, and international case management educator. In her current role as principal consultant for Riverside HealthCare Consulting, she advances programs that promote excellence in care coordination and other transitional care strategies. She has presented more than 400 on-site programs and…

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1. Closing Transitional Care Gaps

In this chapter, we will begin to look at how to close transitional care gaps, with a focus on assessment and communication. Utilizing the Swiss cheese model, we will explore how easy it is for transitional care gaps to occur. The essential elements of transitions of care are identified and defined.

2. Roles and Responsibilities of the Transition Team

One of the biggest risks among the transitions of care from setting to setting is ineffective communication. This chapter looks at the importance of the interdisciplinary handover and the roles/responsibilities of both the sender and receiver of information to ensure gaps are addressed/closed through the patient’s transitional experience.

3. Transitional Care Models

Providing excellent healthcare relies on utilizing best practices. This chapter reviews several transitions-of-care best practices and recent research regarding implementation strategies. Outcome metrics, specifically focused on readmission reduction, are discussed.

4. One Patient's Journey

We will travel along with Ms. Jones on her healthcare journey from acute care to rehabilitation facility to home. Looking at the critical points of transition, we will investigate and identify the gaps in her transitional planning, what could have been more effective, and how to best support this patient along the care continuum.

5. Transitional Care Gaps

Based on our experience with Ms. Jones, we will delve into what exactly can be transitional care gaps, including reflection on the impact of the social determinants of health on a successful care transition. Topics include physical limitations, health literacy, family/caregiver support, and the impacts of psychosocial and financial issues.

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