The United Hospital Fund is a nonprofit that is embarking on an important initiative. Their Difficult Decisions series explores the challenges that hospital staff personnel face in planning discharge.

The third in the series looks at the transition to post-acute care, usually to a Skilled Nursing Facility (SNF). And the study itself brought to light important insights for all providers, in understanding discharge planning, as well as patient transitions, more generally.

The most salient point in the study is, as Fierce Healthcare summarizes, that discharge planning presents profound obstacles for the hospital staff personnel who carry it out. Both administrators and staff very much have a goal of continuity of care. But the tools and structures that staff personnel encounter make the outcome of discharge planning fall short, many times. 

For any of us who work in hospitals every day, none of this comes as a surprise. That said, there were several nuances in the study that were enlightening in exploring when balls get dropped in discharge planning -- and how we might improve that process. 

Why Balls Get Dropped in Discharge to Skilled Nursing Facilities: 

1. Discharge plans are made without real input from the people carrying them out. 
   One thing that I loved about this study is that it was carried out by talking directly to the people who are actually doing the work, in order to understand the real challenges and opportunities they face. For that reason, I think the insights carry more weight than a study solely based on administrators, or findings from a think tank or conference. Similarly, discharge plans are sometimes coordinated "at the top" rather than allowing them to be shaped and reshaped by the medical team, across the continuum of care.
2. Discharge plans are often static. 
   The status of a particular patient changes quickly and often without warning, which means that the discharge plan must change and evolve, too. A static plan won’t work. And one that’s created once and then executed by members of the care team, in their offices or even across institutions won’t work. That’s why a tool like iClickCare -- which uses telemedicine to support medical collaboration for care coordination -- is so crucial. As the patient's situation changes, the entire care team can continue to influence the discharge plan, communicate about status changes, and get multiple perspectives.
3. There is little communication across institutions. 
   Although, in theory, a nurse at a Skilled Nursing Facility, or a doctor at a hospital can always "pick up the phone,"  the pace of medicine and the realities of scheduling makes telephone tag nearly impossible to do successfully. For that reason, there is often little communicate across institutions -- for instance, from a hospital to a Skilled Nursing Facility, or vice versa. That means that information is often fractured and things can get missed, not to mention that crucial nuances of patient care fall by the wayside altogether. 
4. Patients are given information, not guidance. 
   In theory, patients are given the information they need (for instance, a list of skilled nursing facilities). But realistically, they’re not being given the guidance or support necessary to make high-quality decisions about "next steps" in their care. True guidance and support means their whole care team working with the patient collaboratively -- throughout the duration of their illness.

In exploring the findings of this study, it was so clear to me that "trying harder" is not the answer when it comes to healthcare providers doing care coordination and discharge planning effectively. Teams need excellent tools and strong processes to support them in actually creating the continuity of care they intend to. And telemedicine-based medical collaboration is one of those crucial tools. 

You can try iClickCare today to support your organization in doing care coordination as effectively as it intends:

Long Term Care is complex — and it’s no secret that providers have long been doing a lot with a little — providing the best care they possibly can, with limited resources.

The nurses, aides, and other healthcare providers are generally committed, savvy, deeply caring people who provide sophisticated care to people with chronic conditions. And, usually, they receive less support than they should from the broader medical community. Our Long Term Care colleagues report feeling more isolated than they'd like to. 

So, a new report by the New York Times felt a bit blindsiding for our colleagues in the community. 

According to the piece, “Most nursing homes had fewer nurses and caretaking staff than they had reported to the government for years, according to new federal data.” A spotlight was put on facilities that could possibly be "gaming" the Medicare system by over-reporting staffing. And a serious look was given to facilities that have provider shortages on nights and weekends — a serious potential cause of issues like falls.

These issues are serious. And the reality is that skilled nursing facilities need oversight, especially because of the population they serve. These issues certainly shouldn't be downplayed or minimized. As David Stevenson, an associate professor of health policy at Vanderbilt University School of Medicine commented, “Volatility means there are gaps in care. It’s not like the day-to-day life of nursing home residents and their needs vary substantially on a weekend and a weekday. They need to get dressed, to bathe and to eat every single day.”

That said, this New York Times article is written like an exposé. It's written as if the nursing facilities are trying to “pull one over” on Medicare and the public. And, surely — some facilities probably are being dishonest in how they run. But most are trying to do the best possible work they can in an era when there is a shortage for great providers.

For instance, the New York Times references David Camerota, Chief Operating Officer of Upstate Services Group, who said that many nursing homes are in "a constant battle to recruit and retain employees even as it has increased pay to be more competitive."

In our opinion, Long Term Care and skilled nursing facilities would improve more by being offered better tools and more support — rather than more oversight or more scrutiny. We've found that hybrid store-and-forward telemedicine can be transformative in supporting providers in connecting with collaborators outside the walls of their institution — effectively amplifying the manpower of their healthcare providers. When there is a dearth of healthcare providers, care coordination becomes essential. For someone who may be caring for more patients than they should, the ability to ask a question of a specialist or an RN, regardless of the time of day, can mean the difference between a great outcome and a sad one.

Further, in addition to the substantive impacts on patient care, a tool like iClickCare can be powerful for lessening the sense of isolation and alienation that overworked Long Term Care providers can feel. And ultimately, that sense of connection is what we all need — the providers and the patients, alike.

It's easy to feel like better handoffs and better communication is a "nice to have" or something that we can resolve, as providers, once we have more time. 

We hear about tools to facilitate medical collaboration and we tend to think, "Well, that's so nice. Maybe once I get the big stuff resolved, I can move on to refining things like that."

We know from our work with iClickCare that medical collaboration IS one of the big things in medicine, very much not a "nice to have." But a recent study that looked at handoffs and communication from hospitals to Skilled Nursing Facilities (SNFs) really brought this point into relief and made the negative consequences of poor communication at discharge incredibly clear. 

More than 5 million people transition from hospitals to Skilled Nursing Facilities (SNFs) annually. The investigators in this study did detailed focus groups and interviews with SNF nurses, looking at that transition and the communication and medical collaboration that happens -- or doesn't -- and what the consequences are.

It's interesting and smart that the study looks at nurses rather than physicians. There is a lot of investigation around handoffs to physicians, but the handoffs to nurses have been looked at less. And nurses in SNFs play the primary role in managing handoffs and discharge to SNFs. 

The conclusions in this study are fascinating and are also crucial to both SNFs and to hospitals. As the study reports, “Discharge to a SNF is one of the strongest predictors of experiencing rehospitalization within 30 days.” And the study concludes, "High-quality, complete discharge communication is vital to safe and effective hospital-SNF transitions.”

The investigators interviewed 27 registered nurses from 5 SNFs in Wisconsin. Facilities ranged from urban to rural, and from 42 to 184 beds. They spoke with the nurses about handoffs and discharge. And poor quality discharge communication was the major barrier they identified to safe and effective transitions. “From the perspective of SNF nurses, difficult hospital-to-SNF transitions were the norm, and when asked to recall the details of a good transition, none were able to do so.”

The issues they identified are crucial, both because they are significant, specific, and also because they can be easily addressed by existing telemedicine medical collaboration technology. 

Discharge communication issues in Skilled Nursing Facilities (SNFs) that nurses identified:

• The information they get from the hospital is inadequate, incomplete, and incorrect.
  SNFs need specific, up-to-date information about the patient including “remarkable hospital events; written orders for medications, treatments, activity level, and diet; recent and pending laboratory test results; accurate descriptions of functional and cognitive status; and pertinent social information, such as preferences and unique needs.”  Both the medical and the social plan of care are important. And they found that when they do intake for a patient, much of this information was missing or conflicting.
• Information is coming from multiple sources, but they are often conflicting.
  Transition information came from three sources -- the patient, the family, and the hospital -- and they had to synthesize it and try to fill in the gaps.
• There is no good means of communication or collaboration with hospital staff.
  It is very difficult to contact hospital staff for any clarifications or to reconcile discrepancies. They don’t have contact information and don’t have the right contacts.
• Inadequate information, presented in challenging ways, creates care delays.
  At a patient’s arrival, SNF nurses often receive “reams” of paper, sometimes exceeding 80 pages, most of which isn’t relevant to the plan of care. They spend hours navigating records and often have to go through the entire printed electronic health record to figure out an accurate history. Discrepancies are often not reconciled for several days. Nurses often end up going in circles to try to get information, where no one provider actually has all of the information. SNF nurses said, “The primary states… ‘I didn’t know what happened at the hospital so I can’t give you any orders…You need to call the hospitalist or whoever worked with them.’”
• Getting information from families is usually not a good solution.
  Nurses sometimes try to get additional information by asking individuals and families but there are three problems with this approach:
• They often aren’t informed enough to offer quality information.
• Asking them creates a poor impression of the SNF.
• Medical orders are legally binding so they need to reconcile what they hear with the orders.

With all of these issues, nurses say they are mostly “working blindly" when they receive a patient. And that's not a matter of inconvenience, it can be a matter of life and death. The study reports, “Missing or incomplete information resulted in care delays, which threatened individual safety and produced individual and family dissatisfaction with the transition process... In one example, an individual who had bilateral lower extremity casts was left in bed for 1 week as the SNF nurses repeatedly requested and waited for clarification of physical activity orders and cast care.”

Also, these communication issues can be a major problem for the reputation and trust in SNFs. “Care delays and implementation of an inappropriate plan of care resulting from inaccurate information produced significant individual and family dissatisfaction and made the SNF facility appear unorganized and ill equipped to care for individuals. This experience produced substantial stress and frustration in SNF nurses.”

Our frustration in hearing about this kind of problem is huge. Not because it's a concerning public health problem, both in terms of medical provider burnout, and in terms of providing adequate care for our patients... but because we have the tools to fix this. 

Ultimately, this blog is not about advocating for iClickCare as a tool. And if you can find a better telemedicine tool for medical collaboration and communication around handoffs, you should use it. But we see several key reasons why iClickCare a crucial tool to support communication with SNFs, essentially fixing all of the above problems in a simple and cost-effective way: 

• Multiple voices, in one place. 
  One of the primary issues that SNFs face is that there is information coming from multiple providers and sources in multiple institutions and they can conflict with each other. iClickCare keeps all of these voices in one simple patient record, which means that when there are conflicts, they can be resolved quickly. Also, it allows communication across the continuum of care, so that whether it is a physician, generalist, hospitalist, aide, or nurse, all of their experiences about the patient's status can be integrated and incorporated. This also helps ensure that both the medical and social and personal context for care plans can be communicated -- rather than the picture being stripped down to just "orders", leaving nurses to guess about things like cognitive condition or personal context.
• Simple communication for busy people. 
  Nurses in SNFs identified contacting hospital staff -- and even knowing who to contact as a key barrier to effective discharge with adequate communication. With iClickCare, you don't need to play phone tag, hunting down the provider who last saw your patient. You request a consult and the other providers can answer your questions quickly, but on a schedule that works for them, and without needing to track down contact information. Further, words, pictures, video clips, and PDFs can be used to clarify issues and make sure that everyone is on the same page. 
• More efficient development of care plans. 
  It's downright dangerous to delay care for hours or even days because there is inadequate information at discharge and it takes days to resolve the issues. With iClickCare, the process is more efficient because you're using the power of telemedicine to navigate care, asking key questions of the right people.

If you're experiencing communication or discharge challenges in a Skilled Nursing Facility, we urge you to use a telemedicine tool to resolve them. You can try iClickCare for free, for 14 days. Download it here:

At New York Presbyterian, the COO is taking on "respect."

The NEJM Catalyst published an interview with Dr. Laura Forese, who spoke about their new initiative. Their big goal was to cultivate teamwork across the continuum of care, and in surveying the clinicians and non-clinicians at their hospital, they kept hearing that individuals felt like respect was the missing ingredient to their teamwork. So the hospital, under Forese's direction, has been taking action to try to cultivate more respect across the hospital. The intention is certainly there. But when pushed for examples of how they are cultivating respect in the hospital, Dr. Forese gave one primary example: posting a respect credo throughout the hallways.

Many medical providers just gave a little internal eye-roll.

Sometimes it seems like administrators' primary strategy when it comes to almost anything is posting more signs. Not more training, not better tools, not more support, not refined processes -- more signs. 

I certainly agree with New York Presbyterian's goal. Teamwork in any setting is crucial, but in Long Term Care and Skilled Nursing Facilities (LTC/SNFs), teamwork is a matter of life and death on a moment to moment basis. Especially critical, the "team" in a LTC/SNF setting often includes providers across a broader continuum of care than in other settings -- aides, orderlies, housekeepers, families, PT, OT, specialists... the list goes on. 

What I don't agree with is New York Presbyterian's "too easy" approach to such an important topic.

So if the goal of improving teamwork, care coordination, and respect in LTC/SNF settings is valid, then what is the best approach to cultivate that?

We believe there is one key ingredient in improving teamwork in Long Term Care and Skilled Nursing Facility settings: working as a team.

Yes, it really is that simple, but it's not always easy. We get better at running, the more we run. We get better at surgery the more operations we do. And we respect each other more, and function better in care coordination and medical collaboration, when we work together as a team. 

That is precisely the impetus behind iClickCare. We believe that teamwork and collaboration has to be made efficient, fun, effortless, and efficient for healthcare providers to do it. It has to use technology that teams already have, and it has to include every care provider (even non-clinicians, when appropriate). Period.

The best way to improve teamwork is by working together as a team. And the best way to get providers and non-clinicians across your facility to work as a team is to give them the tools to do it in the course of their regular day. Everyone wants to show their colleagues respect -- the important thing is removing obstacles to that, not lecturing about its importance via laminated credos.

If you want to see examples of how telemedicine can drastically improve teamwork in a LTC/SNF setting, click here: