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					Bridging the Information Gap Across the
                     Continuum of Care

        The Key To Successful Transition of Care –
                              A TEAM APPROACH

Danville Cross Setting Workgroup
 Initial Group:         First Meeting: December 3, 2009
 3 Nursing Homes
 Danville Regional Medical Center (Quality Director, Case Management,
  Emergency Room, Risk Management)
 VHQC Facilitator

Goal: Prevent skin breakdown or worsening of an existing pressure ulcer by getting
the necessary skin/wound information about an individual to the next setting.

This required a commitment of everyone involved to renew our focus on the patient at
the center of the transition process, to understand what each setting needs to make
the patient at high risk for pressure ulcers safer and prioritize opportunities identified.

Lessons learned from first meeting:

** Anytime someone will listen to your problems, PEOPLE WILL COME AND

Where do we begin?

1) Outlined the current process for skin assessment in each setting.

2) Identified specific problems

3) Identified resolutions and provided timelines for problem resolution.

4) Needed every person who touched the patient to be involved so we invited additional people to
join the team .

WE NEEDED A TEAM APPROACH!!                                                                        3
                 Pressure Ulcers
A) Problems identified at time of/during transition .
   1) Long wait times in the ER- immobile patients not turned/positioned

   2) Poor communication between the Nursing homes and hospital

   3) Delays in transportation causing possible skin breakdown due to lack
      of turning and positioning.

   4) Some nursing homes had different admission

    Solutions discussed honestly and realistically with assignments for
   follow up given to each member . Accountability for each person was

Changes Implemented:
B) Hourly rounding in the Emergency Room on all patients. (This has been
   implemented hospital wide on all nursing units).

   Place all patients being admitted in a hospital bed if no rooms are
   available at time of admission.

   Nursing checks the patient immediately prior to transportation. If
   transportation is delayed, the agency will contact the nurse on the unit.

   Nursing Homes call the patients Case Manager or nurse to inform them
   if the resident has an ulcer.

   Ensure consistent documentation of High Risk and Pressure Ulcer
   stage/current treatment goes with the patient to each setting.

Communication - The Key to
Every Successful Team
 Biggest Problem in Our Process:
 ◦ Lack of consistent communication and tools.

  SBAR (Situation, Background,
  Assessment, Recommendation)
  Many tools evaluated by the team.
 Trial and Error. It’s OK to make mistakes!
 Don’t reinvent the wheel, look at what you are
  already using.
 EVERYONE follows the decision made by the

Communication Con’t
Tools we decided to use:
 1) Phone call to Nursing Home to give them a verbal report. If no answer,
  send written standard report. Have a designated line to call for each
  nursing home and a contact person .
 2) For transportation issues/concerns, we decided to have a contact person
  at the hospital who would follow up concurrently on any issues. A
  transportation contact person was also assigned for the hospital to contact
  for any concerns/issues.
 3) The Director of Information Systems started a year long process of
  obtaining consent from corporate to give electronic access to all nursing
  homes. This was approved in October, 2011. This allows consistent,
  accurate patient information to all nursing home facilities to ensure
  continuity of care. Access to all of the patient’s information enables all
  providers to have all documentation needed to put the patient as the top

“Coming together is a beginning; keeping together is
 progress; working together is success."
 Henry Ford  

             Other Improvements Made!

1) Improving Discharge Disposition Codes- Nursing Homes to
contact Case Management if the disposition code changes from
stated code at time of discharge. Less than 1% error monthly.
2) Do Not Resuscitate Forms – a copy of the DNR form for Virginia
is accepted during transport (in case the original is not available).
3) High volume of admissions causing delays in discharged
patients leaving. Transportation agency added new shifts and trucks
to meet the needs of the community.
4) Education provided to all nursing units on how to complete the
Physician Certification Forms as they arrange this on the weekends.
5) Case Management to notify transportation agency when heavy
discharges expected so they can rearrange staffing, call in
additional staff when needed.
6) Hospital Respiratory Therapy Department provided education to
local Nursing Homes on nebulizer treatments, new trach care and
providing competency check off for NH nurses.

                Improvements Con’t
 7) Transportation agency purchased new ventilator due to cross
  setting discussions.
 8) Improvement in pain management for all patients by routinely
  providing pain medication prior to transportation pick up.
  9) Forum for all settings to inform of changes, new services available   .
 10) Identified specific personnel in the nursing home, hospital, and
 transportation agency to call if any issues need immediate resolution.
 11) Heart Failure Coordinator provided education to nursing homes
 on Congestive Heart Failure to assist with assessment and maintain
 stabilization of CHF patient.
 12) Policy was written regarding controlled substances not stocked in
 EMS medication box for EMS Transport from DRMC.
 13) Assistance in ensuring correct equipment is returned to the
 correct place (i.e. wheelchairs, O2, etc)

Many Opportunities; Many
 “ At times our own light goes out and is

rekindled by a spark from another person.

Each of us has cause to think with deep

gratitude of those who have lighted the flame

within us.”

Albert Schweitzer

 Danville Regional Medical Center
 Riverside Health and Rehab
 Gretna Health and Rehabilitation Center
 Piney Forest Health and Rehabilitation Center
 Stratford Rehabilitation Center
 Roman Eagle Memorial Home, Inc.
 Chatham Health and Rehabilitation Center
 Vans Med Tech
 Regional One Transportation


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