In my last post, I discussed how important the admission process is for building trust with the new resident and their families/ loved ones. This rapport may help to avoid unnecessary hospital readmissions if the resident/ families can trust that the facility is carefully assessing the resident’s needs and working in their best interests. This trust building involves all staff and continues after admission. It requires consistent observation and communication by housekeeping staff, nurse assistants, dietary, nurses and therapists alike. The process includes the in-depth evaluations and assessments of the Interdisciplinary Team (IDT) members – forming an individualized plan of care. This plan culminates with the Nurse Practitioner (NP)/ Physician Assistant (PA) and physicians, orchestrating the team via orders and close direction to meet the identified needs of the resident in order to truly be successful. It takes the whole team!

The Gatekeeper Process

In my prior post, I wrote that I had the opportunity to work with an organization that had a Gatekeeper process in place that effectively managed care in order to avoid unnecessary hospital transfers. The process began with admissions, but it went much further. Best practice requires that the Gatekeeper process be solid. Other than an emergency 911 transfer, if the nurse feels the resident requires a different level of care, the resident is to be assessed by the nurse with the assistance of a flow chart guide. It works like most flowcharts:  “If this is observed, did you complete this?” or “If this is observed, did you do this?” Various trigger points are built in that include instructions as to when to contact the NP or physician to receive orders. Orders may include advanced nursing care, with IV’s for hydration, respiratory services, new medications and additional observation, etc.

Not only did this approach have the nurse reviewing and documenting resident status, it made the nurse think about what could and should be done at the facility.  It made them think about what they should be doing to prevent a discharge - what signs and symptoms they needed to be evaluating during each med pass, and ultimately it improved their nursing and assessment skills.  It also improved their communication to the nursing assistants as to what to watch for and report if seen.  If the nurse utilizing the flowchart process and evaluating the resident thought the resident may need to be transferred, they were required to take their evaluation and concerns to the Gatekeeper who would complete an additional review of the assessment and the resident needs, ensuring  that all that could be done at the facility level was being done. This could include an onsite evaluation by the NP/PA or the physician.  Many facilities are taking this more aggressive approach and utilization of resources more seriously – especially due to the focus on Quality Measures and potential hospital alliances being tied to hospital readmission rates.

The NP/PA/Medical Director and physicians on staff at your facility must also understand and buy into the Gatekeeper program; therefore you must ask for their assistance in the education process. They seldom get the opportunity to educate at nursing facilities, but if they believe it will reduce unnecessary transfers or enhance staff knowledge they are generally happy to oblige. I have yet to find any who have declined an invitation to teach staff and or residents/families on best practice.

Knowledge, commitment and continual process review are required once you have implemented your Gatekeeper process.  Don’t be afraid to create a QAPI regarding your re-hospitalization/discharge process, it shows you care and that you are working to address the situation - which is exactly what the survey teams are looking for.  Include the entire team; they will work to ensure success.  Listen to your staff, including external staff such as physicians, Nurse Practitioners or Physician Assistants and to your residents and family members to hear what they have to say about your care and build upon that. Continue to assess patient satisfaction as well.  Remember there is no easy fix. For a successful Gatekeeper process, it takes on-going education, communication, team building, staff rapport and a sense of security and trust for this process to be successful.  Regardless if you have to create or improve upon your Gatekeeper program: don’t delay - begin today.