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Transitions of Care: Reduce Hospitalizations in SNFs Part 1

presented by Cathy Wollman

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Disclosure Statement:

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

Non-Financial: Cathy Wollman has no competing non-financial 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.

MedBridge is committed to accessibility for all of our subscribers. If you are in need of a disability-related accommodation, please contact [email protected]. We will process requests for reasonable accommodation and will provide reasonable accommodations where appropriate, in a prompt and efficient manner.

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This course features an interactive case study. For the best experience, please watch this course on a desktop or laptop computer.

This course will introduce skilled nursing facility (SNF) administrators and staff to quality transitions of care for SNF residents. Emergency room (ER) visits and readmissions for SNF residents are common, expensive, and result in complications for frail residents. SNFs are accountable for avoidable, preventable, or unnecessary hospital re-admissions. Each member of the interprofessional team plays a role in prevention of poor outcomes for residents. This course will provide an overview of transitions of care and the critical need to improve transitions within SNFs. A discussion of person- centered care and comprehensive resident information required to provide quality care is included. Best practice models are discussed with the focus on communication and safety, including medication reconciliation. The course will conclude with a brief case study of a typical high-risk resident transferred from acute care to the SNF.

Meet Your Instructor

Cathy Wollman, DNP, RN, GNP-BC, CRNP

Dr. Wollman has been an educator and clinician for more than 35 years. She has worked as a gerontologic nurse practitioner at multiple sites of care across the health care system. She also served as director of senior health for a large health system and the coordinator of the nurse practitioner program for more than…

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Chapters & Learning Objectives

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1. Introduction to Transitions of Care For SNF Residents

This chapter will define transitions of care and their effect on residents at the time of admission to the SNF and subsequent transitions, including discharge to home. Barriers to effective transitions and statistics that characterize the complex and challenging aspects of transitions of care in the SNF will be reviewed. Common high-risk characteristics of SNF residents that make them susceptible to poor outcomes will be discussed.

2. Resident and Family Engagement for Safe Transfers of SNF Residents

This chapter will discuss the need for person-centered care, communication and safety during transitions of care. The focus of the chapter will be on transition planning, essential information that supports quality transfers, and the requirements for education and engagement of the resident and family during transitions. The role of the enhanced interprofessional team in the transitions of care process will be evaluated. Participants will have an increased awareness of the need for ongoing assessment, communication, education, and documentation for high-risk residents.

3. Healthcare Provider Engagement For Safe Transfers Of SNF Residents

This chapter begins with a discussion of safe medication reconciliation. Additional focus is on essential follow-up care and the roles of each health-care provider in quality transitions of care. Requirements for enhanced communication between sites of care and roles of accountable clinicians is emphasized. Evidence-based models of transitions of care are included. The goals of patients and families will be highlighted as part of the plan of care.

4. A Case Study Of The Typical High-Risk Resident

This chapter presents a case study of a typical high risk resident admitted to the SNF. The focus will be on comprehensive person-centered care, communication and safety. The case will synthesize the Part I discussion of evidence based transitions of care.

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