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)
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
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
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,
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
EVERYONE follows the decision made by the
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."
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.
7) Transportation agency purchased new ventilator due to cross
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
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