Improving transitions of care across the spectrum of healthcare delivery: A multidisciplinary approach to understanding variability in outcomes across hospitals and skilled nursing facilities

Giana H Davidson; Elizabeth Austin; Lucas Thornblade; Louise Simpson; Thuan D Ong; Hanh Pan; David R Flum

doi:10.1016/j.amjsurg.2017.04.002

Improving transitions of care across the spectrum of healthcare delivery: A multidisciplinary approach to understanding variability in outcomes across hospitals and skilled nursing facilities

Am J Surg. 2017 May;213(5):910-914. doi: 10.1016/j.amjsurg.2017.04.002. Epub 2017 Apr 5.

Authors

Giana H Davidson¹, Elizabeth Austin², Lucas Thornblade², Louise Simpson³, Thuan D Ong⁴, Hanh Pan³, David R Flum⁵

Affiliations

¹ Department of Surgery, University of Washington, Seattle, WA, USA; Department of Health Services, University of Washington, Seattle, WA, USA. Electronic address: ghd@uw.edu.
² Department of Surgery, University of Washington, Seattle, WA, USA.
³ Chief Health Systems Office, University of Washington, Seattle, WA, USA.
⁴ Department of Medicine, University of Washington, Seattle, WA, USA.
⁵ Department of Surgery, University of Washington, Seattle, WA, USA; Department of Health Services, University of Washington, Seattle, WA, USA.

Abstract

Introduction: Improving coordination during transitions of care from the hospital to Skilled Nursing Facilities (SNF)s is critical for improving healthcare quality. In 2014, we formed (Improving Nursing Facility Outcomes using Real-Time Metrics, INFORM) to improve transitions of care by identifying structural and process factors that lead to poor clinical outcomes and hospital readmission.

Methods: Stakeholders from 10 SNFs and 4 hospitals collaborated to assess the current hospital and system-level challenges to safe transitions of care and identify targets for interventions.

Results: The INFORM collaborative identified areas for improvement including improving accuracy and timeliness of discharge information, facilitating congruent medication reconciliation, and developing care plans to support functional improvement.

Discussion: Hospital and SNF stakeholder engagement prioritized the challenges in patient transitions from inpatient to skilled nursing facility settings. Innovative solutions that address barriers to safe and effective transitions of care are critical to improving clinical outcomes, decreasing adverse events and avoiding readmission.

Publication types

Consensus Development Conference

MeSH terms

Delphi Technique
Hospital Administration / methods*
Hospital Administration / standards
Humans
Interdisciplinary Communication*
Outcome and Process Assessment, Health Care
Patient Readmission / statistics & numerical data
Patient Safety
Patient Transfer / organization & administration*
Practice Guidelines as Topic
Quality Improvement / organization & administration*
Skilled Nursing Facilities / organization & administration*
Washington

Grants and funding

T32 DK070555/DK/NIDDK NIH HHS/United States