Communication Cathy Bachert, RN, Director, Quality Molly Nadeau, RN, MBA, Director Case Management Cape Cod Hospital, Hyannis MA

All Communication is Not Equal “No one would talk much in society if they knew how often they misunderstood others. “ — Johann Wolfgang Von Goethe WE STOPPED TALKING TO EACH OTHER!!!! Purpose of this presentation

The Problem Nurses in the SNFs would rely on the information abstracted from the patient’s medical record There were no planned opportunities to speak to the nurses at the hospital Although they could call, it was generally not done

We Communicated to the Wrong People SNF Screeners reviewed written materials and communicated to the SNF Charge Nurse 7-3 SNF Admissions were frequently on the 3-11 shift Nurse at CCH did not know the patient

Relationships  Paper work did not contain those bits of information that nurses could share one on one about the patient SNF nurses felt intimidated about calling the hospital nurses. “Don’t want to bother them” Lack of Trust on both sides

Aim Statement Aim: Develop a nurse to nurse verbal communication process between the Skilled Nursing Facility (SNF) admitting nurse and the hospital discharging nurse by April 15th, 2011.

Expected Results SNF nurse obtaining all information needed to care for the patient and make informed decisions Especially helpful when communicating with physicians about potential need for transfer back to the hospital This communication will ultimately result in a decrease in readmissions

Create a New Process Set an expectation that there would always be a call for the patient handoff Flow of clear identifiable process steps with assigned responsibilities for both the SNF nurse and the hospital RN.   Education of the staff at both SNF and Hospital – Nurses, Case Managers, and Nurse Unit Managers.

Eliminate the Middle Man Create a process for direct communication between caregivers Identify clear defined steps to that process Test the process and gain feedback

Nurse to Nurse Communication What if we gave the nurse who was accepting the patient at the SNF direct communication about that patient from the nurse who was discharging the patient? Nurse with the most information gave that information

Nurse to Nurse Communication SNF Decision is made Hospital Case Manager will provide to liaison or SNF Admissions Coordinator the 4 elements The SNF fills in form with the patient -nurse identifiers and the hospital 4 elements SNF Nurse reviews patient info previously provided by hospital SNf Nurse prepares questions based upon info review prior to calling hospital, utilizing form The SNF Nurse Calls Hospital Nurse prior to planned transfer to SNF Hospital discharging Nurse gives hand-off report to SNF Nurse, allowing for questions Add pertinent information to the patient care plan and communicate to appropriate staff Hospital transfers patient to SNF SNF receives patient SNF RN completes admission assessment. Calls hospital with any unresolved issues or concerns. SNF RN communicates plan of care and patient's goals to care team.

Anticipated Push Back – “One More Thing” How could we create a process that would pull instead of push back? Which Nurse most needed the information? Did the nurses find value in the call?

Let’s Ask The Nurses!! Hospital RN Staff Meetings Revealed: We don’t have time We will end up doing their work for them They already get that information, will we be repeating the same information?

Something Surprised Us and Helped Us Novice Nurses were at the staff meetings who worked also at the SNFs They voiced a valid reason for the call – All Patients can be “Scarry” especially without a verbal report Appealed to a new EC to Inpatient process that recently left RNs feeling unsure

Was it Valuable? “Did the Nurse to Nurse Call Add Value?” We wanted to know: So we asked the nurses from the SNF and also from the Hospital side utilizing a formal audit tool

What will we measure? Did the call occur? Time of the call: Did call occur prior to transfer? Did the call add value to the information needed to care for the patient? Duration of call Number of calls by SNF about the same patient Did the call address a common cause or a potential readmission?

Value - Overwhelming Yes 95% of the time – Yes Time of call = less than 5 minutes per call What went wrong? SNF nurse not prepared and used call to screen information already provided in writing Hospital Nurse did not always have the same view of the issues from their perspective

Conclusion Nurse to Nurse Communication was and is a success SNF and Hospital Nurses have reconnected Trust is being restored Readmissions have been avoided – case study

MD Communication / Appointment Molly Nadeau, RN, MSN, Director Case Management MD Communication / Appointment

What Happened to PCP Communication? Problem: PCPs were out of the loop on their patient’s admission and discharge from the hospital. PCPs reported reading about patient death in the news paper obituary column.

We stopped talking to each other! Background Hospitalist vs. PCP Attending patients in hospitals Medical Records no longer mailing hard copies of the discharge summary PCPs in offices not computer savvy – don’t read automatic e-mails We stopped talking to each other!

MD Notification Form Faxed at discharge Unit Secretary responsible Form edited several times to include more detailed information Added the Clinical Resume and Medication List to the faxing

Measuring the Process Compliance initially at 67%; Currently at 79% Intervention: Unit Secretary meeting Frequent Rounding and Reinforcement of form Feedback from Physicians – they liked it!!

MD Appointments Clear Expectations developed and communicated: Who would be responsible to call MD office? What patient population needed MD appointment? How many days after discharge? What if the doctor could not accommodate ? How is it going?

SNF Readmission Audit

Why Audit SNF Readmissions?

What Should We Look At?

What To Do Next? What number of patients are sent to the EC and returned? (New Study) Review “ Real Time” Review of all unplanned readmissions. Increase Skill Level – Nursing (Critical thinking Education on care guidelines process) IVs Low freq. high impact “Support Teams” Real time training ( On the Spot ) Interact Program – Fully Integrated into SNF day to day work Develop nursing practice guidelines- Disease Specific Share Hospital Care Maps and protocols VNA Share care maps with SNFs Med Rec – Dovetail. Identify patients at risk for readmission on admission Refer discharged patients for pharmacy consult with VNA End of life Improvements

Just Do It! Create your own “Nurse to Nurse Process” PCP Notification MD Appointments Study the SNF Population: Partner for success

Our Staff / Our Greatest Resource Leadership is Key Staff left alone to define, revise and implement will fail A Leader will emerge It may not be the one you expect LEAD THE CHANGE AND CHALLENGE YOUR TEAM TO BECOME THE BEST!