With so many acute care facilities using hospitalists to render treatment to in-patients, primary care physicians (PCP) no longer round and are often missing updates on their hospitalized patients. By streamlining processes through technology, from the initial referral to our skilled nursing facility through the time of the admission, GHN works to identify each patient’s PCP and any other specialists who were among the patient’s care team prior to hospitalization. Care managers in the field and in the hospital recreate the patient’s healthcare journey to ensure complete communication among all parties once the patient arrives to the post-acute care setting. This is a recent development. In the not so distant past, a skilled nursing facility would rely upon its medical director to manage each and every patient, without the benefit of a robust medical history. In addition, there was no process in place for the medical director to communicate with a patient’s PCP or other specialists.

 

GHN has transformed the treatment team process by formalizing its transitional care coordination. A transitional care coordinator along with an advanced registered nurse practitioner (ARNP) at the skilled nursing facility work closely with the patient, the patient’s family, decision makers and other interested parties, and the interdisciplinary healthcare team . The transitional care coordinator and ARNP drive the communications between the patient’s PCP and skilled nursing facility physician, ensuring the patient’s positive long-term prognosis. Advanced technology provides the transitional care coordinator with touch points and pathways that will assure the appropriate move for a patient from the skilled nursing setting to the community. Follow up with the patient by the transitional care coordinator continues for up to 90 days afterward.

 

At the heart of GHN’s transitional care coordination efforts is effective communication. The benefits of this new practice are already being reflected in improved patient outcomes and a more efficient sharing of information among the key players in the patient care team. Collaborative communication is not simply sharing of information, but rather a fostering of shared meanings which are apparent when providers work together for the highest quality treatment and outcomes possible. GHN is proving that true every day in each of its facilities.