While strong admission assessments are needed to ensure that the interdisciplinary team (IDT) creates a timely baseline care plan, directors of nursing services (DNSs) may want to beef up their pre-admission assessments to improve their IDT’s ability to provide person-centered care that addresses quality-of-care and quality-of-life needs right out of the gate, especially for skilled short-stay patients, suggests Kristin Bernard Breese, BSN, RN, CPC, RAC-MT, owner of Post-Acute Clinical Advisors LLC in North Granby, CT.
“Historically, many SNFs looked at potential admissions strictly from a financial perspective,” notes Breese. “However, the Reform of Requirements for Long-term Care Facilities increased surveyors’ focus on incorporating the resident’s voice—their personal and cultural preferences—into care goals, as well as improving quality of care and quality of life.”
In addition, there are now multiple Quality Measures (QMs) monitoring SNF performance on hospital readmissions and other care/treatment issues across three programs: the Five-Star Quality Rating System on Nursing Home Compare, the SNF Quality Reporting Program (QRP), and the SNF Value-Based Purchasing (VBP) program, says Breese. “Even referring hospitals have publicly reported readmission rates that they also need to manage.”
Patient satisfaction is also an issue. “Staff members may spend hours per day talking about patients (e.g., at shift change),” she points out. “However, patients often feel like communication is an issue because staff never seem to talk about what they think is important, and the patients have to wait until the next day or over the weekend for someone to look at an issue. Identifying and taking care of issues before admission to the SNF can make a better impression on the patient and family.”
To optimize care and maintain or boost referrals in the current environment, DNSs need to shift focus and ask: “How can my team do a good job of managing this patient from day 1 when they come in the door?” says Breese.
“Of course, how to do a good job is a question providers have always asked, but often it’s asked once the resident is in the SNF,” she points out. “For example, if a resident comes in on a Friday afternoon, the IDT may not ramp up care until Monday morning even with the baseline care plan in place. The result is three days where the IDT may not be doing what needs to be done. A strong pre-admission assessment can make your IDT more proactive—and limit the potential reactivity that can overshadow good quality of care, causing residents and families to stress.”
Steps that can ensure the best pre-admission assessments possible include following:
Establish a strong working relationship with case managers
In some states, SNFs aren’t allowed to visit skilled Medicare patients in the hospital prior to admission to the SNF, notes Breese. “If that’s the case, you need to become friendly with hospital case managers to ensure they will be willing to give you the hospital records needed to get a clear picture of the patient.”
Talk to family members (and/or the patient if possible)
Contacting a family member or resident representative pre-admission gives DNSs information to educate staff before the patient has a complaint, says Breese. “You want to provide care the right way from the beginning and not wait to correct course when someone complains. So ask the family, ‘Tell us what we need to know to be ready.’ Communicating with the family prior to admission helps them feel like we already know the patient when they’re admitted.”
Put a nurse on your team
A nurse needs to be involved in the admissions process, says Breese. “A layperson in the admissions office cannot assess information the same way that a nurse can. Certain red flags will spark a nurse to investigate further. For example, if a nurse sees certain combinations of medications, they will be able to notice that a diagnosis may be missing from the patient’s medical record.”
“You need to know what medications the resident is on,” says Breese. “Do these meds have serious side effects? Do your staff understand the medications? Can you manage the medications? Could the resident manage these drugs at home if they leave the SNF (because, for skilled residents, the general assumption on pre-admission is that these people won’t live in the facility forever)? For example, sometimes insulin is really delicate, and it is just not feasible. So you want to look at the medications with an eye toward anticipating what your team will have to do and what kind of education you need to plan for.”
Look at prior hospitalizations, diagnoses, and behaviors
“You want to find out how many times the patient has been in the hospital,” says Breese. “Are they a frequent flyer? And if they are, what are they frequenting with? For example, are they a CHF patient? A COPD patient? A behavior patient? Or are they a true short-stay patient who, for example, may need extensive teaching?”
The goal is to review all of the clinical indicators and anticipate what kind of track the patient needs to be put on when they arrive, she explains. “You look at your staff and ask: Where is the best place to put this patient so they can succeed and have an appropriate discharge? Different units often do better with different types of patients. For example, units that are faster-paced tend to do better with ortho patients.”
Determine whether you need to outsource services
“When you are developing this picture of the patient, you should determine whether your staff can handle their care needs or you need to have available vendors on-site,” says Breese. “For example, if a potential resident has significant CHF or COPD and you don’t have respiratory therapists in-house, you may want to tell the vendor, for example, ‘I’m going to need a respiratory therapist twice a week’ before the patient is admitted to your facility. With the sustained emphasis on quality, you can’t afford for a patient who is admitted on a Friday night to wait until Monday morning to receive that initial respiratory treatment that they really need over the weekend.”
Assess the patient’s previous living conditions
“Is the resident doing well at home, or not doing well at home? Do they have a spouse? Do they have family support?” says Breese. “Often, a family member or resident representative can supply this information, which can help you determine upfront what systems you need to put in place to reduce the chances of a hospital or SNF readmission.”
Find out about personal, religious, or cultural preferences/restrictions
“You want to ask about dietary restrictions, cultural and religious issues, and preferences from a customer perspective but also to determine whether your staff can handle these requests,” says Breese. “Do you need to do an education with your staff prior to the patient’s admission about, for example, a certain religion?”
Here are three scenarios where problems can occur when staff don’t know about patient’s preferences and needs prior to admission:
· Scenario 1: In SNFs where patients have extremely short stays (e.g., two to four days for a hip or knee replacement), those patients increasingly have technology-based business and personal interests, notes Breese. “Three or four days of being totally disconnected from their online world can be a major issue for these patients. So you need to find out what their activities are: Are they bringing a computer? Do they need a computer? Do they need wi-fi? Do they need access to a printer? You don’t want to admit a patient who then tells your staff, for example, ‘I need a printer in my room and a television I can use with my Fire Stick.’”
In addition, providers want to avoid situations where they ask patients what they expect and then just don’t provide it, she stresses. “If you make alternate plans before they’re admitted (e.g., networking the patient to a printer at the nurses station instead of giving them their own printer), both the patients and your staff will be less frustrated.”
· Scenario 2: Some patient preferences can have a direct impact on care, says Breese. “For example, if you find out from the family that a patient is a light sleeper, you may need to put them on a quieter unit vs. a busier unit—and it’s better to do that on admission than several days later when, for example, they’re too tired to participate in therapy.”
· Scenario 3: Cultural and religious issues can be especially challenging for SNFs, says Breese. “For example, if you’re not a kosher facility, you need to know prior to admission that a patient requires a kosher diet so that you don’t admit a patient before you figure out how to feed them. In addition, if you start receiving more kosher patients, you need to be sure to address that in your facility assessment.”
Learning about religious and cultural issues pre-admission can protect staff as well as patients, she adds. “For example, one facility I worked with admitted a nonverbal patient after a stroke. He was extremely aggressive with staff to the point that the facility was considering discharge. When staff asked the family about the situation, they finally told the facility that his religion didn’t allow him to be seen naked by a woman who isn’t a relative. If the admissions team had asked about religious and cultural issues before this patient was admitted, the provider could have avoided a dangerous and stressful situation.”
“Make sure that the pre-admission assessment paints a picture that makes sense. If it does not paint the picture that you think it should, you need to investigate,” says Breese. “One common issue is that medications and diagnosis codes don’t always match up. For example, a patient who has a diagnosis of diabetes may not be on any diabetic medications or on a diabetic diet.”
So admissions staff need to ask questions before the patient is in the SNF, says Breese. “You don’t want to be in a situation where a resident is admitted on a Friday night, and then you find out that you can’t provide appropriate care (e.g., you’re not equipped to provide an IV push that the physician has ordered). No other facility will take that patient at midnight on a Friday, so you will have to make accommodations that you could have avoided if you had gotten a clear picture of the resident’s needs in the pre-admission assessment.”
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