MAKING CARING CONNECTIONS CONTINUITY OF CARE TRANSFER PROJECT Staff Education Presentation

1. MAKING CARING CONNECTIONS CONTINUITY OF CARE TRANSFER PROJECTStaff Education Presentation LTC Facility Presenter�s Name Date

2. OVERVIEW OF PROBLEM Insufficient communication between hospitals and long term care communities during care transfers� adversely affects the quality and continuity of care provided contributes to adverse events and increased health care costs The Missouri Department of Health and Senior Services� Best Practice Coalition � which includes long-term care administrators and associations, physicians, the Missouri Hospital Association and other professionals interested in the quality of care provided in LTC centers� recognized insufficient communication between hospitals and LTC centers during transfers of care were adversely affecting the quality and continuity of care provided and were contributing to adverse events and increased health care costs. Today, I will present an overview of a transfer process developed by the Best Practice Coalition in collaboration with hospitals and LTC centers to improve continuity of care. This collaboration resulted in the determination of the essential information needed to be communicated and the development of a process and tools to improve handoff communication when transfers occur between hospitals and LTC centers. DHSS Best Practice Coalition Goal for this project was to� �Consistently and accurately provide health care workers basic health care information when LTC residents are transferred to and from hospitals and LTC communities.� The Missouri Department of Health and Senior Services� Best Practice Coalition � which includes long-term care administrators and associations, physicians, the Missouri Hospital Association and other professionals interested in the quality of care provided in LTC centers� recognized insufficient communication between hospitals and LTC centers during transfers of care were adversely affecting the quality and continuity of care provided and were contributing to adverse events and increased health care costs. Today, I will present an overview of a transfer process developed by the Best Practice Coalition in collaboration with hospitals and LTC centers to improve continuity of care. This collaboration resulted in the determination of the essential information needed to be communicated and the development of a process and tools to improve handoff communication when transfers occur between hospitals and LTC centers. DHSS Best Practice Coalition Goal for this project was to� �Consistently and accurately provide health care workers basic health care information when LTC residents are transferred to and from hospitals and LTC communities.�

3. CASE DISCUSSIONS: PROBLEMS WE FACE WHEN TRANSFERS OCCUR Use this slide to discuss situations in your own LTC center where the quality and safety of a resident was compromised during a transfer to and from a hospital. Depending on the audience, you may want to include examples of LTC residents seen in the ED and transferred back to the LTC facility and residents who were directly admitted to a hospital and discharged back to your LTC center. Use this slide to discuss situations in your own LTC center where the quality and safety of a resident was compromised during a transfer to and from a hospital. Depending on the audience, you may want to include examples of LTC residents seen in the ED and transferred back to the LTC facility and residents who were directly admitted to a hospital and discharged back to your LTC center.

4. CONTINUITY OF CARE The goal of this project is to improve communication and relationships between hospitals and LTC centers by consistently and accurately providing basic health care information when LTC residents are transferred to and from hospitals and LTCs. By making these caring connections, we will ensure the continuity of care and quality and safety for our patients. There are a few basic principles to ensure continuity of care and effective transfers. ACCOUNTABILITY - All staff members and physicians must be accountable for ensuring the timely exchange of appropriate information when transfers occur. COMMUNICATION � To improve transitions in care, staff and physicians should clearly and directly communicate the patient�s diagnoses, treatment plan, what is needed and the expected follow-up. This also includes care plan, baseline and current assessments and all pertinent history and test results. TIMELY � Appropriate information should be exchanged between providers as quickly as possible. This includes timely receipt of the final physician discharge summary. INVOLVEMENT AND AWARENESS OF PATIENT AND FAMILY � Every step of the way the patient and/or family need to know who is responsible for care at that point, who to contact and how. Nothing should occur without input from the patient and/or family every step of the way. The goal of this project is to improve communication and relationships between hospitals and LTC centers by consistently and accurately providing basic health care information when LTC residents are transferred to and from hospitals and LTCs. By making these caring connections, we will ensure the continuity of care and quality and safety for our patients. There are a few basic principles to ensure continuity of care and effective transfers. ACCOUNTABILITY - All staff members and physicians must be accountable for ensuring the timely exchange of appropriate information when transfers occur. COMMUNICATION � To improve transitions in care, staff and physicians should clearly and directly communicate the patient�s diagnoses, treatment plan, what is needed and the expected follow-up. This also includes care plan, baseline and current assessments and all pertinent history and test results. TIMELY � Appropriate information should be exchanged between providers as quickly as possible. This includes timely receipt of the final physician discharge summary. INVOLVEMENT AND AWARENESS OF PATIENT AND FAMILY � Every step of the way the patient and/or family need to know who is responsible for care at that point, who to contact and how. Nothing should occur without input from the patient and/or family every step of the way.

5. BEST PRACTICE COALITION RECOMMENDATIONS incorporate the recommended data elements into the forms used when transfers occur between LTC centers and hospitals adopt the continuity of care transfer process use the forms consistently and follow the recommended process To meet these principles, the coalition recommends all hospital and LTC centers do the following. incorporate the recommended data elements into the forms used for transfers between LTC centers and hospitals adopt the continuity of care transfer process use the forms consistently and follow the recommended process To meet these principles, the coalition recommends all hospital and LTC centers do the following. incorporate the recommended data elements into the forms used for transfers between LTC centers and hospitals adopt the continuity of care transfer process use the forms consistently and follow the recommended process

6. WHAT IS THE CONTINUITY OF CARE TRANSFER PROCESS? complete the appropriate transfer form fax the form to the receiving facility send a copy of the form and recommended medical records with EMS or the family call the receiving facility to give verbal report During the transfer process, the coalition recommends the following procedures for all hospitals and LTC centers. complete the appropriate transfer form fax the form to the receiving facility send a copy of the form and recommended patient/resident records with emergency medical services or the family call the receiving facility to give a verbal report communicate key information with receiving physicians During the transfer process, the coalition recommends the following procedures for all hospitals and LTC centers. complete the appropriate transfer form fax the form to the receiving facility send a copy of the form and recommended patient/resident records with emergency medical services or the family call the receiving facility to give a verbal report communicate key information with receiving physicians

7. WHY SHOULD WE DO THIS? Improve quality, safety and continuity of care during care transitions Improve handoff communication and transfer of information Decrease medical errors Reduce the number of duplicated tests Increase resident satisfaction Reduce resident complaints and litigation Save staff time and frustration Meet Joint Commission Safety Goals ALL FACILITIES will benefit by improving the efficiency and effectiveness of transfers. Potential benefits include the following. Improve quality, safety and continuity of care during care transitions Improve handoff communication and transfer of information Decrease medical errors Reduce the number of duplicated tests Increase resident satisfaction Reduce resident complaints and litigation Save staff time and frustration Meet Joint Commission�s National Patient Safety Goals (if accredited by the Joint Commission) ALL FACILITIES will benefit by improving the efficiency and effectiveness of transfers. Potential benefits include the following. Improve quality, safety and continuity of care during care transitions Improve handoff communication and transfer of information Decrease medical errors Reduce the number of duplicated tests Increase resident satisfaction Reduce resident complaints and litigation Save staff time and frustration Meet Joint Commission�s National Patient Safety Goals (if accredited by the Joint Commission)

8. LTC TRANSFER PROCESS OVERVIEW Complete at time of emergency transfer or planned admission Send a copy of forms and records with EMS or family, fax forms to hospital and retain one copy for LTC record Give a nurse-to-nurse report to receiving hospital ED or unit The form should be completed whenever a resident is transferred to a hospital for emergency evaluation or planned admission. Whenever possible, complete the form before the transfer. In an emergency, it may be necessary to complete the form after the resident has left the facility. Copies of the transfer form and medical records listed on the form should be placed in a large envelope and addressed to the hospital. This envelope should be given to the person, family or EMS transporting the patient, with instructions to give to the receiving hospital. In an emergency, it may be necessary to fax the documents after the resident has been transported. Call the receiving hospital and give a nurse/CNA-to-nurse report. �The form should be completed whenever a resident is transferred to a hospital for emergency evaluation or planned admission. Whenever possible, complete the form before the transfer. In an emergency, it may be necessary to complete the form after the resident has left the facility. Copies of the transfer form and medical records listed on the form should be placed in a large envelope and addressed to the hospital. This envelope should be given to the person, family or EMS transporting the patient, with instructions to give to the receiving hospital. In an emergency, it may be necessary to fax the documents after the resident has been transported. Call the receiving hospital and give a nurse/CNA-to-nurse report. �

9. ED TRANSFER PROCESSOVERVIEW Population: All ED patients being transferred back to skilled, intermediate and assisted living facilities and other post-acute care facilities Complete form prior to discharge Fax copy to LTC facility Call LTC facility and arrange for discharge needs including resident�s need for new prescriptions and give a nurse-to-nurse report The ED physician should communicate key information to the LTC physician prior to discharge Send one copy of form with EMS or family Maintain copy for ED record Complete the handoff communication form before discharge. Before discharge, fax the form to the receiving facility. Call the receiving facility to give a nurse-to-nurse/CNA report. The ED physician should communicate key information with the LTC physician. A copy of the form and the records should be placed in a large envelope and addressed to the post-acute care facility. This envelope should be given to the person, family or EMS transporting the patient, with instructions to give to the receiving facility. �Complete the handoff communication form before discharge. Before discharge, fax the form to the receiving facility. Call the receiving facility to give a nurse-to-nurse/CNA report. The ED physician should communicate key information with the LTC physician. A copy of the form and the records should be placed in a large envelope and addressed to the post-acute care facility. This envelope should be given to the person, family or EMS transporting the patient, with instructions to give to the receiving facility. �

10. HOSPITAL TRANSFER PROCESSOVERVIEW Population: Patients being transferred to skilled, intermediate and assisted living facilities and other post-acute care facilities Complete prior to discharge by nursing staff. Fax completed form to the receiving facility. Call receiving facility and give a nurse-to-nurse report. Give a copy of the form and other discharge documents to the persons (family or EMS) transporting the patient. If new prescriptions are ordered, fax prior to noon on the day of transfer. Place the original copy of the form in the medical record. Nursing staff are to complete the transfer forms prior to discharge. If applicable, a copy of the completed Page 1 and medical records necessary for acceptance should be faxed to the receiving facility before planned discharge. Before the transfer, fax the handoff communication forms to the receiving facility. Call the receiving facility to give a nurse-to-nurse/CNA report. Copies of the forms and other discharge documents should be placed in a large envelope and addressed to the post acute-care facility. This envelope should be given to the person, family or EMS transporting the patient, with instructions to give to the receiving facility. If new prescriptions are ordered, fax to the nursing home before noon on the transfer day to ensure no interruptions in the patient�s prescriptions. The attending physician should communicate key information with the LTC physician. �Nursing staff are to complete the transfer forms prior to discharge. If applicable, a copy of the completed Page 1 and medical records necessary for acceptance should be faxed to the receiving facility before planned discharge. Before the transfer, fax the handoff communication forms to the receiving facility. Call the receiving facility to give a nurse-to-nurse/CNA report. Copies of the forms and other discharge documents should be placed in a large envelope and addressed to the post acute-care facility. This envelope should be given to the person, family or EMS transporting the patient, with instructions to give to the receiving facility. If new prescriptions are ordered, fax to the nursing home before noon on the transfer day to ensure no interruptions in the patient�s prescriptions. The attending physician should communicate key information with the LTC physician. �

11. FORMS AND GUIDELINES Long-Term Care Handoff Communication Form Emergency Department to Long-Term Care Handoff Communication Form Hospital to Long-Term Care Handoff Communication Form At this time, walk through all of the forms using the guidelines as your resource with the staff. Be sure to cover not only the LTC forms but also the ED and hospital forms so staff are aware of what hospitals have been requested to do. Be sure to emphasize that the forms and process may vary from facility to facility. At this time, walk through all of the forms using the guidelines as your resource with the staff. Be sure to cover not only the LTC forms but also the ED and hospital forms so staff are aware of what hospitals have been requested to do. Be sure to emphasize that the forms and process may vary from facility to facility.

12. PERFORMANCE MEASUREMENT How we will measure the project�s success, effectiveness and performance Performance Measurement Tools Chart Reviews Focus Groups Inform staff on what performance measurement and compliance monitoring tools will be used and how and when they will be used. Be sure to let them know that their feedback is vital to the success of this program and that you welcome their recommendations for improving the process.Inform staff on what performance measurement and compliance monitoring tools will be used and how and when they will be used. Be sure to let them know that their feedback is vital to the success of this program and that you welcome their recommendations for improving the process.

13. FREQUENTLY ASKED QUESTIONS Review the Frequently Asked Questions section of the toolkit utilizing the questions which are most pertinent to your audience.Review the Frequently Asked Questions section of the toolkit utilizing the questions which are most pertinent to your audience.

14. Wrap-up, answer questions and secure a commitment from staff to support the project. Wrap-up, answer questions and secure a commitment from staff to support the project.