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Hospitalists Improving Transitions of Care Through Virtual Collaborative Rounding with Skilled Nursing Facilities-the
Ifedayo O Kuye1, Sonia Dalal2, Shaker Eid2
1Division of Hospital Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA. ikuye1@jhmi.edu.
Background:
Over one in five Medicare patients discharged to skilled nursing facilities (SNFs) are re-hospitalized within 30 days of discharge. Poor communication between the hospital and SNF upon hospital discharge is frequently cited as the most common cause of readmission.
Aim:
The goal of this program was to assess the ability of a weekly post-discharge hospitalist led virtual rounding program to augment the written discharge summary sent to SNFs.
Setting:
Two academic hospitals and six SNFs in Baltimore, MD.
Participants:
Hospitalists and medical directors or directors of nursing from the partner SNF.
Program Description:
During weekly encounters, the hospitalist and SNF providers discussed the clinical status, discharge medications, treatment plan, and follow-up care of all discharged patients. The intervention took place from July 2021 to December 2021.
Program Evaluation:
During the study, 544 patients were discussed in a post-discharge virtual encounter. After the discussions, hospitalists identified clinically significant errors in 124 discharge summaries. A survey of participating hospitalists and SNF medical and nursing leadership indicated the intervention was thought to improve care transitions.
Discussion:
Our innovation was successful in identifying errors in discharge summaries and was thought to improve the transition of care by participating SNF and hospitalist providers.
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