When it comes to enhancing outcomes for individuals who are being admitted, cared for and ultimately discharged from skilled nursing facilities (SNFs), continuity of care is paramount for everyone involved.
First and foremost, continuity helps to ensure that residents receive the proper care in your facility as soon as they enter based on their unique circumstances. It also provides caregivers comprehensive and accurate information when it’s time to discharge the resident—either to their home, another SNF, an acute-care hospital or, in some cases, an emergency room. And from the standpoint of your SNF, it helps you maintain Quality Measures at desirable levels, avoid costly penalties, function at optimal efficiency and build a winning culture for employees and residents alike.
In this blog, we highlight five best practices for SNFs in relation to discharge functions.
Best practice #1: Get prepared early on.
It may surprise you to learn that optimal discharge practices begin before a resident is even admitted to your SNF. Facility personnel tasked with discharge responsibilities should try to learn as much as they can about that resident’s situation from the outset. That entails gathering information about how that specific discharge will likely unfold. Will the resident return home? Does he/she even have a home to return to? What kind of equipment needs are there at that landing spot? Who is the resident’s primary care giver and primary physician? Your discharge staff should have answers to these and other relevant questions before residents are even admitted into the facility. In a broader sense, you should avoid situations where individuals are admitted to your SNF and then discharged into unsafe circumstances.
Best practice #2: Establish ownership of discharge responsibilities, including oversight.
Who’s responsible for what tasks and roles in the discharge process? How does discharge occur, and under what conditions? Your SNF’s policies and procedures should provide clear answers.
Best practice #3: Communicate with PPNs around discharge to remain a preferred provider.
Communication with PPNs is key—and at no time is this truer than during discharge. If you’re sending a resident home, let your PPN contacts know when that resident will be discharged, and how well that resident fared in your facility. Conversely, if it’s necessary to send a resident back to the hospital, specified personnel should call the report to the acute-care nurse or case manager at that hospital.
Best practice #4: Be proactive in communicating with each resident post-discharge.
While this has long been an industry best practice, we’ve found that few SNFs actually follow it. Given the negative consequences of hospital readmission for everyone involved, post-discharge communication is a simple and effective step to help ensure continuity of care.
It’s not complicated. In fact, it can be as simple as a designated staff member calling a discharged resident within 48 hours of their discharge and just checking in. For example: “Ms. Jones, how’s it going? How are you doing at home? Have you received your medication? Has your home health person been out to see you?” Too often, medications and/or home health personnel don’t arrive at a discharged resident’s home, and that individual winds up in the hospital as a result. Basic communication can resolve problems early on, before they become serious.
Beyond the initial post-48-hour communication, we at Richter recommend that SNFs continue periodic follow-up with discharged residents for up to 30 days.