SENIOR SERVICES

Goal is to improve the quality of care for seniors by providing exceptional care for seniors. 2

Collaboration 3

Root Cause Analysis: 4 Nursing facility residents are frequently subject to avoidable hospitalizations. These hospitalizations are expensive, disruptive, and disorienting. Nursing facility residents are vulnerable to risks that accompany hospital stays and transitions between nursing facilities and hospitals. Avoidable hospitalizations among nursing facility residents stem from multiple system failures. Studies have estimated that as much as 30-67% of hospitalizations among nursing facility residents could be prevented with well-targeted interventions.

Root Cause Analysis (continued): 5 System failures include: - Lack of communication of relevant medical information across the continuum of care. - Lack of shared education resources between hospitals and nursing facilities focused on improving clinical depth of staff, including critical thinking skills, clinical skills and communication skills related to care of the elderly.

Proposed changes in care delivery model that are under consideration (continued): 6  Partner with nursing facility staff to implement preventative services and improve recognition, assessment and management of conditions such as CHF, COPD, asthma, UTI, dehydration, skin ulcers, palliative care and falls.  Establishment of protocol implementation for management of conditions such as: palliative care, CHF, COPD, asthma, diabetes, hypoglycemia, change in condition recognition and urinary incontinence, UTI, dehydration, anticoagulation, tube feedings, skin care, skin ulcers.

Proposed changes in care delivery model that are under consideration (continued): 7  Establish specific consistent hand off protocols for inpatient, outpatient, ED, ambulatory services of SSM-St. Louis facilities and the nursing facility partners. - Physician/provider to physician/provider communication. - Nurse to nurse communication. - Documentation protocols. - Medication reconciliation.