Beds at a premium? Reduce avoidable readmissions.

One hospital's approach to effective care transitions

Hospital beds are at a premium worldwide, which means that reducing avoidable readmissions is a top priority for just about every organisation we work with. Nurses can help by ensuring seamless, high quality care transitions between the acute and post-acute care settings.

The nursing teams at Oregon Health Sciences University (OHSU) Hospital, a progressive US hospital, and Prestige Care Inc., a large US post-acute care organisation, partnered to create a new dedicated care transition role.

The skilled nursing facility (SNF) transfer expert role takes advantage of the videoconference component of a telemedicine program. OHSU started their telemedicine program in 2012 and then began working with Prestige Care to create videoconference 'warm handovers'.

'Warm handovers' enable the nurses, patient, and patient's family at the hospital to see and speak with the post-acute facility staff who will soon assume care responsibility for the patient.

Break down care silos to facilitate seamless cross-continuum care

"We've been able to discuss with patients what their priorities are before they come here, what their expectations are", Prestige Care's Darlene Gayheart explained. "We've been able to look at wounds, we’ve been able to look at incisions, and gain insight from the nurses caring for the patient at the acute level so we have some understanding of where they've been in their journey and what their specific needs are coming forward into our facility."

The telemedicine program has so far produced measurable positive results. Readmissions to the hospital from post-acute care centers participating in the telemedicine program dropped almost 7% for all patients between 2012 and 2013. Among patients 65 and older, readmissions dropped 12% during the same period.

Video handovers are just one component of a comprehensive strategy OHSU and Prestige Care have employed to reduce avoidable readmissions. They also created a simple assessment tool that captures objective information, like length-of-stay and haemoglobin levels, to identify patients who are at high risk for readmission.

Get the full story from OHSU and Prestige Care Inc.

In this member-led webconference, two US organisations explain how the newly created skilled nursing facility (SNF) transfer expert role helped reduce avoidable readmissions.

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