Transitions of Care: Reduce Hospitalizations in SNFs Part 2

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This course will continue to explore quality transitions of care in the skilled nursing facility (SNF). Medicare financial changes that necessitate improved transitions of residents in SNFs will be discussed. Quality Improvement (QI) tools available for assessment, documentation, and communication between staff, providers, and families will be analyzed. Recommendations to improve the facility’s transitions of care program will include interventions for safe transfer of residents from acute care, management of residents within the SNF, and discharge planning for transfers back to the resident’s home. The course will conclude with a Q&A session with an expert in the field, to evaluate unique concerns about transitions of care in the SNF.

Meet your instructor

Cathy Wollman

Dr. Wollman has been an educator and clinician for more than 35 years. She has worked as a gerontologic nurse practitioner at multiple sites of care across the health care system. She also served as director of senior health for a large health system and the coordinator of the nurse practitioner program for more than ten…

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Chapters & learning objectives

1. Hospitalization of SNF Residents and Changes in Reimbursement

This chapter examines the types of avoidable, preventable, or unnecessary hospital admissions from the SNF. An overview of evolving Medicare financial and reporting changes related to transitions of care is included. Participants will have a greater understanding of accountability for members of the interdisciplinary team in prevention of poor outcomes.

2. Quality Improvement (QI) Tools to Improve Transitions of SNF Residents

Quality Improvement tools and strategies are available to assist SNF staff in early identification, assessment, communication, and documentation of changes in resident status. There is a focus on tools to identify early changes in resident status. This chapter will support the facility’s use of recommended QI tools to improve quality of high-risk resident care and to reduce hospitalization rates.

3. Expand and Improve Transitions of Care Programs in the SNF

This chapter will review the steps involved in transitions of care for SNF residents. Available evidence will be included to support quality care for each phase of the transition process. Recommendations to improve policies and procedures in the SNF will assist facilities to enhance their reputation in the community and prevent unnecessary transitions of care.

4. Panel Discussion With SNF Leaders

This chapter will include a panel of SNF leaders and staff to discuss their unique experiences with transitions of care. The panel will provide an opportunity to hear additional problems, concerns, and solutions to issues related to transitions of care for SNF residents.

More courses in this series

Transitions of Care: Reduce Hospitalizations in SNFs Part 1

Cathy Wollman