Open Forum

I manage a team of 18 registered nurses who are engaged in population health for the quality department for 26 primary care practices in New Jersey. We contact patients immediately upon discharge from hospitals and other facilities to perform Transitional Care Management. One area that we are struggling with is notification of discharge from a subacute facility and getting discharge summaries from those facilities. We are required by our CMS program to contact patient with 48 business hours and to schedule PCP follow up in 7-14 calendar days but this population is difficult to track. I am wondering if anyone else across the country has found a solution to this issue with SAR discharge communication.

Thank you!

Tammye Ross, MSN, RN-BC, CMSRN
Manager Practice Transformation
VIRTUA Health
Marlton NJ 08053
Tross@virtua.org

Hello Tammy,

Post discharge contact is such an important part of care coordination and transition management. Kudos on your established process and goals to focus on this area to decrease readmission rates and to close gaps that exist. The facility that I work at utilized the AHRQ - Agency for Healthcare Research and Quality Re-Engineered Discharge (RED) Toolkit | Agency for Healthcare Research and Quality (ahrq.gov) when we worked on improving our process.

When the facility I previously worked at was having difficulty in getting admission and discharge information the team set up a meeting with the leadership in those locations. They planned several meet and greets across the state with the facility leadership to discuss some of the barriers, challenges and ways to work together to reach mutual goals. This is how business relationships were built and enhanced and they found a way to enhance the communication through establishing care coordination agreements (CCA)to define expectations between our organizations. Maybe this is something you could do virtually or in person as well! 

Thanks,

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Jami Falk MS RN-BSN CNML
VHA OPC PCMO Chief Nurse
VHA
Bismarck ND
(701)367-5431
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Tammy, 

I am the Post Acute Care Navigator for our ambulatory offices. We use a platform called Olio Health. I run reports including our inpatient discharges to SNF and Docs4Docs review for outside discharges. I upload patients who are discharged to SNF into the platform and can communicate with SNF partners regarding patient status, can share documents (dishcarge summaries, med lists, labs, vitals, imaging, ACP documents), and stay up-to-date on the patient status. This has allowed us to increase our ACO goals for PAC Nav from 12% follow up to over 70% follow up for Medicare population as well as increase TCM follow up dollars tremendously. We started with them in May 2023 and have prevented readmissions. We are also able to follow the patient in home health as well in Olio. I highly recommend looking into their service. I'm happy to connect you with them if you'd like. 

Jessica Henline

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Jessica Henline, BSN, RN
Chronic Care/Post-Acute Care Coordinator
Hendricks Regional Health
Danville, IN
jessica.henline@hendricks.org
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