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

2. 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

3. 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

4. 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

5. 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

6. 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.

7. 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

8. 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.

9. 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

10. 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

11. 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.

12. 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?

13. 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?

14. 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

15. 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

16. 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?

18. 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

19. 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

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

21. 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.

22. 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 s
We stopped talking to each other!

23. 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

24. 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!!

25. 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?

26. SNF Readmission Audit

27. Why Audit SNF Readmissions?

28. What Should We Look At?

30. 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

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

32. 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!