The field of skilled nursing medicine is in transition. Patients are being transferred to skilled nursing from acute hospitals earlier in the course of their recovery than in years past. Thus they need a higher level of medical care when they arrive at the skilled nursing facility.
At Spherical Medical we are committed to being leaders in developing protocols and standards of care to engender the highest quality of care in the post acute setting.
Currently we are focusing our quality improvement efforts on transitions of care. With attention to communication between providers at the time of care transition we believe we will accomplish the following:
- Provide a better patient experience and clinical outcome
- Reduce unnecessary readmissions to the hospital
- Decrease duplication of studies and labs
- We discuss the patient’s course and plan with the discharging hospital physician prior to transfer.
- We have access to the electronic medical records of the discharging facility.
- We have protocols in place to optimize the prompt delivery of medications and needed supplies to the skilled nursing facility soon after patient arrival.
- We see the patient at time of discharge.
- We make sure the medications are reconciled and that a list of medications reaches the primary care provider.
- We write a discharge note to be sent to the primary care provider.
- We set up and work closely with home health agencies and durable medical equipment providers.
- We make sure that the patient is being discharged to a safe environment.
- We contact the Emergency Department to make sure they understand what our concerns about the patient are.
- We inform the Emergency Department provider of what resources are available in the nursing home setting.
4) Hospice Transition
- We communicate with the Palliative Care team at the hospital.
- We work closely with hospice in the skilled nursing facility to make sure the patients needs and wishes are met.