Communication Tool Helps Reduce Hospital Readmissions

Effective communication is essential to high-quality healthcare. atom Alliance team members in Indiana are successfully facilitating improvement in transitions of care with the Wabash Valley Care Coalition (WVCC). They are using a communication tool that encourages openness and clarity as a patient’s care is transferred from one member of the healthcare team to another. Healthcare providers refer to this approach as a “warm handoff.”

The tool provides the admitting nursing home staff the opportunity to ask key questions of the hospital discharge staff during the transition to provide clarity and transparency and avoid miscommunication. It ensures the receiving provider has all relevant documentation and information to minimize disturbances in care and services. This approach emphasizes person-to-person communication rather than reliance on documentation alone.

The WVCC is focused on improving the transfer of patients from a hospital setting to a skilled nursing facility (SNF) and has a goal of reducing 30-day hospital readmissions by 20 percent in the community by 2019. They identified communication barriers between hospitals and nursing homes and together decided to try the tool as a solution. Members of the WVCC revised the tool after careful review to optimize it for the participating providers. A pilot project to implement the tool began in August 2016.

A Learning Curve

Initially, the discharging nurses on two units in the hospitals were to initiate usage of the tool during their transfer report over the phone. The tool guided them to ensure that critical information is communicated and the admitting nurse at the nursing home had the opportunity to ask questions.

“After the first month of data collection, it was clear that hospital staff were not using the tool,” said Ann Hayworth, atom Alliance quality improvement advisor.

The hospitals continued to educate and promote the use and benefits of the tool with the support of the WVCC and atom Alliance. With feedback from the pilot project, they revised the tool more than ten times to adapt it to the needs of the providers.

“One barrier was that only two units at each hospital were chosen, which provided confusion for the hospital and nursing home staff,” said Hayworth.

(click to view example of tool)

So the WVCC members changed their focus to nursing facilities, encouraging them to use the tool for every transfer, regardless of hospital unit distinction, if not already initiated by the hospital discharge nurse. Facilities began including the form in the admission packets for the admitting nurse to complete. The form was not a part of the official patient record, but acted as a communication tool between nurses for the first 24-48 hours of a new resident’s stay.

Gaining Momentum

Currently, 21 nursing facilities (75 percent) in the Coalition are participating in this initiative and implementing the tool during the first 24 to 48 hours of the patient’s transfer.

“We have noticed more providers accepting the tool as a useful way to prevent mistakes and keep the families involved in their loved one’s care,” said Hayworth. “Three participating hospitals are now training all of their nursing staff hospital-wide with the tool.”

The tool’s utilization rate has grown. One facility’s use of the tool increased from 87 percent to 100 percent in fewer than six months. That means every new resident transferring from a hospital to that nursing home is getting transparent and thorough care, reducing the chance for readmission into the hospital.

One nursing facility reported they believe the communication tool was effective in preventing the readmission of a high-risk resident who had transferred to their facility during a weekend from a hospital. The tool provided consistent and detailed information for the nursing home team receiving the patient and the various caregivers from shift to shift. The nurses on duty were well informed and open, which fostered a positive relationship with the patient and family members. The patient received high-quality care throughout the transition and did not need to be readmitted to the hospital.

The WVCC is recruiting additional committed participants and spreading the tool to other post-acute care providers, including home healthcare, transportation and hospice agencies. Members of the Coalition plan to review the tool for recommended changes from the users once a year. Many nursing facilities reported they plan to make it a standard part of their intake process.

The atom Alliance Difference

“atom Alliance team members in Indiana help the coalition by providing a learning environment, keeping them focused, leading discussions and actively listening. Our expertise in tracking team success, workflow assessment and tool development helps them make decisions to keep improvement efforts moving forward,” Hayworth said.

For more information about the WVCC or the warm handoff tool, contact atom Alliance quality improvement advisor Ann Hayworth at ann.hayworth@area-g.hcqis.org.