Accreditation The American Medical Directors Association (AMDA) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
Designation Statement: The American Medical Directors Association designates this educational activity for a maximum of 3.5 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.
AMDCP Credit Designation: This session has been approved for a total of 3.5 Management credit hours toward certification as a Certified Medical Director in Long Term Care (CMD).
Session Description: This session describes a continuous quality improvement process updating transfer processes designed for convenience, patient safety and associated with low hospital readmission rates. Methods adopted by nursing home administration and attending physicians insuring completeness of the process will also be presented. In addition, it will define the scope of the issue of rehospitalization in subacute care nationally and describe an innovative program to reduce transfers out to the hospital. Examples of how electronic medical records are being used to educate patients and families on discharge will be discussed.
Discuss the nature of rehospitalizations nationally, the costs to our health care system, and how some organizations have successfully lowered rates.
Describe an innovative program that has lowered rehospitalization rates using: 1) Identification of high risk patients and early goals of care discussions 2) Automatic palliative care team consult 3) Team Improvement for the Patient and Safety (TIPS) multidisciplinary conferences for root cause analysis 4) Project RED on discharge home.
Examine how online medical record can be used to empower patients and demonstrate teach back of both patient and family prior to discharge from a subacute unit.
Discuss how team culture can be changed by bimonthly case reviews of patients that have been transferred out to the hospital.
Evaluate how convenience and patient safety can be built into a hospital-to-nursing home transfer system.
Describe the community-wide design and input from both hospital and nursing homes necessary for successful transfer processes.
Discuss how nursing homes and their attending physicians can control the completeness of transfer materials.
Speakers(s): Randi Berkowitz, MD, CMD (Moderator); Sharon Verney, NP; Robert J. Schreiber, MD, CMD; David Sandvik, MD, CMD; Priscilla F. Bade, MD, CMD
Disclosure(s): Randi Berkowitz, MD, CMD has no financial disclosures to report. David Sandvik, MD, CMD has no financial disclosures to report. Robert J. Schreiber, MD, CMD has no financial disclosures to report. Sharon Verney, NP has no financial disclosures to report. Priscilla F. Bade has no financial disclosures to report.