Senior Man Sitting In Hospital Bed
5th Dec

We will be changing the way we do business in the PAC world in the upcoming years. That’s a given. There are so many legislative changes going on for PAC right now it’s very difficult to keep up with. There is no doubt that CMS has issued directives to decrease length of stay and hospital readmissions.


With the focus on seamless transition of care to the next level we may see the term “discharge” go away.

All levels of care should frame their minds to focus on transitioning the patients, not discharging. Let’s examine some of the barriers every level of care experiences.

It’s critical to communicate with the patient and family. Most people in our care still have the goal to return to home, therefore, this will need to be discussed from the beginning. It’s never been more important than now to begin discussions of transitioning to the next level of care (formerly known as “discharge”). Many facilities are utilizing the white boards in patient rooms to document their expected length of stay. By setting this goal and talking about it with the patient and family you are establishing a relationship where they will trust that your focus is on quality care which produces good outcomes. Also, by displaying the expected date of transition, all care providers are aware and should be able to work towards this common goal. Many patients and families have been taking a more active role in their care, and in many cases; they tend to be better informed about their disease processes. Clear communication of expectations keeps everyone on the same page.

If the patient is not going home with self-care, it’s also vitally important to have a means to communicate with the caregivers in the next level of care.     Until a trusted method of ensuring interoperability of healthcare information is available, you may need to create a format that will fulfill these needs. Best practice for a seamless transition is to meet with your referral base and ensure the means of communication is suitable for both parties. Create a format that ensures all necessary information including patient safety is communicated to the next level of care.  An example of this is having the Case Manager/Nurse Navigator/Transition Care Coordinator from a SNF meet with the Home Care companies to discuss what information HHC organization needs for safe transition. Next step would be to work with your care partners to develop means of communication. Many companies are using this opportunity to create a flowsheet or report tool specific to their organization’s needs. This can apply for any transition; Hospital→EMS→SNF→LTC→EMS→Hospital→Home Care→Hospice…the list goes on. You get the picture; the point is that you have to ensure that the tool you use for a seamless transition of care must include the necessary patient health and safety information and service both the sending and receiving care givers.

With the focus on Quality and Safety of patient care it is imperative that all levels of caregivers consistently receive thorough and correct information at the handoff. This is one problem that has long plagued caregivers in all settings; providing adequate report for a seamless handoff. With shorter length of stays it is never more important than now to get this right.

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