Rethinking transitions of care: An interprofessional transfer triage protocol in post-acute care

Area of Science:

• Gerontology
• Healthcare Management
• Quality Improvement

Background:

• Rising hospital readmissions from post-acute care (PAC) units increase healthcare costs.
• Financial penalties for long-term care facilities regarding readmission rates are imminent.
• Effective strategies are needed to reduce 30-day preventable hospital readmissions.

Purpose of the Study:

• To evaluate the impact of an interprofessional team (IPT) and a Transfer Triage Protocol on reducing 30-day preventable hospital readmissions.
• To assess the potential for a 10% reduction in readmissions within six weeks of implementation.

Main Methods:

• An interprofessional team (IPT) developed and implemented a Transfer Triage Protocol.
• The protocol was used in conjunction with the INTERACT program to guide clinical decisions.
• Quantitative and qualitative analyses were employed to assess outcomes and identify areas for improvement.

Main Results:

• A 35.2% reduction in the 30-day preventable hospital readmission rate was achieved.
• Qualitative findings indicated a need for enhanced staff education and improved communication processes.
• Increased on-site availability of the IPT was also identified as beneficial.

Conclusions:

• The pilot study demonstrated the effectiveness of an IPT-led Transfer Triage Protocol in reducing hospital readmissions from PAC settings.
• The intervention shows significant benefits for improving care quality and decreasing readmission rates.
• Further implementation requires addressing staff education, communication, and IPT support.