1. MAKING CARING CONNECTIONS: CONTINUITY OF CARE TRANSFER PROJECT Management Presentation Hospital Presenter’s Name Date

2. OVERVIEW OF PROBLEM Insufficient communication between hospitals and long term care communities during care transfers…  adversely affects the quality and continuity of care provided  contributes to adverse events and increased health care costs

3. HISTORY OF THE PROJECT Best Practice Coalition identified the problems associated with transfers. Appointed workgroup to find solutions.  reviewed literature, standards and regulations  conducted hospital and LTC surveys  created a recommended transfer process, drafted model transfer forms and guidelines Conducted a pilot with hospitals and LTC centers Revised forms and process based on pilot Best Practice Coalition recommended the process and forms be adopted as a best practice

4. CONTINUITY OF CARE

5. BEST PRACTICE COALITION RECOMMENDATIONS incorporate the recommended data elements into the forms used when transfers occur between LTC centers and hospitals adopt the continuity of care transfer process Use the forms consistently and follow the recommended process All hospitals and LTC centers should do the following.

6. THE CONTINUITY OF CARE TRANSFER PROCESS complete the appropriate transfer form fax the form to the receiving facility send a copy of the form and recom mended medical records with EMS or the family call the receiving facility to give verbal report All hospitals and LTC centers should do the following.

7. CASE DISCUSSIONS: PROBLEMS WE FACE WHEN PATIENTS ARE TRANSFERRED

8. WHY SHOULD WE DO THIS? Improve quality, safety and continuity of care during care transitions Improve handoff communication and transfer of information Decrease medical errors Reduce the number of duplicated tests Decrease readmissions Increase patient satisfaction Reduce patient complaints and litigation Save staff time and frustration

9. WHY IS THIS IMPORTANT TO OUR HOSPITAL? NQF has proposed improved care transitions from one setting to another as one of its 2009 priority goals. CMS has made care transitions part of its 9th Scope of Work. Included in two of the Joint Commission National Patient Safety Goals New CMS Quality Measures focus on 30-day readmission rates. Addresses many of the hospital-acquired conditions for which CMS proposes to withhold payment

10. HOW DO WE GET STARTED? Identify a project champion and key players at your facility Establish goals and benchmarks Review current forms and processes Review project tools, forms and resources Adopt or modify transfer forms and guidelines Educate staff Do it! Review, evaluate and revise Celebrate and share successes

11. CONNECTING WITH LTC FACILITIES Extend invitation to participate in a communitywide project Ask them to identify a project champion and key players at their facilities Host meetings to establish and promote transfer standards Execute communitywide plan

12. MAKING CARING CONNECTIONS …will make our residents and patients safer and make relationships between hospitals and nursing facilities stronger. Jeffrey A. Kerr, D.O., CMD