How Do I Improve Collaboration During SNF Transitions?

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A Skilled Nursing Facility, or SNF, is a post-acute care facility where nurses, under the supervision of a medical doctor, provide care to patients as the patient recovers before transitioning home. SNFs have a lot of patients quickly transfer in and out of their facility. However, these transitions can be error-prone due to collaboration obstacles. Keep reading to learn more about collaboration challenges SNFs face, and suggestions for improving collaboration during transitions. 

Collaboration Problems

Clinician-to-clinician collaboration can be a big challenge as patients transition from hospitals to SNFs, especially when it comes to sharing patient information.  In one study, information sent from the hospital to the SNF was delayed “sometimes” or “often” for over 50% of SNF-hospital pairs. In interviews, SNF providers said they often received missing or mismatched information from hospitals during patient transfers, which adds extra work and makes it more difficult to provide care. 

Part of this collaboration challenge is the methods and tools used to coordinate care. In a study, 76% of hospital-SNF pairs reported at least one shortcoming with usability regarding information sharing. This isn’t surprising, given that over 60% of post-acute care facilities rely on phone calls to transfer patient information or clinical details. When organizations use different EHR systems, it can be difficult to share patient notes. The notes may be delayed, or some may need to be faxed if they cannot transfer into the new EHR system. Sometimes a discharge summary and patient notes may be delayed because a clinician hasn’t finished writing them, and the SNF cannot see any of the information until the note arrives. This can lead to phone calls and messages as the SNF needs to provide care when the patient arrives, even if the note has not. 

Information sharing issues impact clinicians when patients are discharged home. In interviews of patients and their caregivers post-SNF discharge, patients described how not all their relevant health information was available to their home care providers and PCPs, with patients needing to fill in the gaps. PCPs and home health providers should have all the information from the patient’s hospital and SNF stay so that the providers can continue the patient’s care plan. Relying on a patient’s memory of care plans may lead to information being inaccurate or missed. 

Clinicians and patients also have collaboration issues about care plans upon discharge. A survey found that only 42% of patients and caregivers reported they received sufficient medication instruction during the patient’s stay at the SNF. When they go home, they do not necessarily understand what they are supposed to do, which can negatively impact outcomes. This may also result in lots of messages and phone calls between patients or their caregivers and providers, taking extra time for clinicians as they have to go back to that patient’s chart and provide instructions multiple times, instead of once. 

Suggestions for Improving Collaboration During Transitions

Improve Patient Education

One way to help improve collaboration during transitions is to improve patient education. A SNF did an intervention on medication education, where they had nurses review medication with patients and their caregivers within three days of the patient’s admission, and then again before discharge. Patients’ understanding of their medications improved from 60% to 94% after the intervention. 

When providing education to patients, it’s important to ensure that patients understand what you are saying. Using a method like the teach-back method can help when providing discharge education to ensure that patients understand what to do. The teach-back method is when the clinician asks the patient to explain what they understood from the visit, care plan, etc. This way, if the patient is unclear they can ask, or the clinician can clarify any misunderstandings or add in any information they forgot to say initially. When using this method, it’s important that it does not come across as a test for the patient, but as a way for the clinician to see if they were providing clear instructions in a way that the patient can understand. 

Providing patients with educational videos can also help their care at home and chronic disease management. While there is a lot of information available online, it can be difficult to sift through everything and determine what information is reliable and accurate. When organizations provide educational videos to patients, they are ensuring that the videos provide accurate information, that the information is easy to understand, and that it is relevant to the patients’ health. This has the potential to improve how patients adhere to their treatment plan and improve outcomes. 

Schedule Communication Times

Scheduling time for different communication tasks improves collaboration. First, scheduling time means that different providers can all be focused on the same patient, and they have time to prepare in advance if they want to. This also ensures that there is ample time to communicate fully, and not in a rush in-between patients. 

For example, scheduling a discharge planning meeting for each patient can improve communication. Whether the meeting is just the clinical team or includes the patient can be up to each organization, but this gives clinicians an opportunity to all focus on the same patient and address any questions or ambiguous items about the patient’s care plan. Another example is scheduling a follow-up call with the patient within 72 hours of discharge, where the clinician can check in on the patient, ask how the patient is following their treatment plan, and answer any questions the patient has. 

Get More Access to Data

Health information exchanges, or HIEs, are electronic collections of health information that are securely shared among clinicians and health organizations. HIEs can show the nursing facilities where the patient has previously received care and provide information from those encounters. So if there is a delay in getting records sent, clinicians at the SNF can use the HIE to find patient information in real time. Health technology can work with HIEs to organize the data and bring the right information to the right clinician at the right time. Learn more about how health technology works with HIEs here.

Enhance Clinical Care Coordination

Improving coordination between clinicians is another strategy to improve SNF transitions. When patients transition from a hospital to a SNF, care team collaboration technology can help clinicians share patient information in real-time, even if providers use different EHRs. When patients transition from SNFs to home, clinicians can use this tech to share information with home health providers and the patients’ PCP.  It’s important that this technology is EHR-agnostic, as each organization may use a different EHR, which can make sharing notes more time-consuming and cumbersome. Strong care coordination tools can greatly improve communication for better outcomes. 

CareAlign is an EHR-agnostic care coordination tool that helps clinical teams collaborate in real-time to provide the best care for patients. CareAlign has recently started working with Tandigm Health to improve collaboration during transitions to SNFs. Learn more about CareAlign here