presented by Cathy Wollman
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.
Dr. Wollman has been an educator and clinician for over 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 over ten years at Neumann University in Aston, PA. She worked as one of the first advanced practice nurses in transitional care research at the University of Pennsylvania twenty years ago. Dr. Wollman has more recently taught nurse practitioner courses in an online college of nursing. She has presented at multiple national conferences on aging topics including transitional care, dementia, falls, and health literacy.
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.
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.
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.
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.