Facility procedures for ensuring recognition of acute changes in condition become the building block for managing those changes in condition and become the cornerstone for any program designed to prevent hospital readmissions within a skilled nursing facility.   Communication of all resident-related information should follow a defined process that includes involvement of all interdisciplinary team members.  Much like it becomes everyone’s responsibility to answer call bells, all staff should be trained and have a clear understanding that it is their job to communicate any findings that might represent an acute change of condition in a resident.    My last blog entry on this topic made recommendations for delineating staff roles and responsibilities for identifying, analyzing, managing, and communicating information about acute changes of condition.  In addition, in-depth of acute changes of condition should be communicated at specific times such as change of shift report, during the 24 hour report, and at the daily Medicare meeting.

A suggested approach for management of the acute change of condition would be to identify those residents who have a high risk for acute change of condition and consequentially return to the hospital.   I would consider prioritizing a detailed care plan for these residents much like a care plan is identified for those residents who are at high-risk for pressure ulcers and falls.  The following items should be included:

  • Evaluate the resident’s current condition and status
    • Document the resident’s baseline
    • Determine the expected course and known complications in specific conditions
    • Define causes and problems identified to date
    • Identify risk factors that could result in negative outcomes
    • Identify candidates for palliative care and hospice

Create a care plan that focuses on matching diseases and conditions with consequences and risks.  Then identify interventions that might help to reduce those risks and prevent complications.  INTERACT 2 Care Paths offer condition specific assessment protocol for the following conditions:  acute mental status change, fever, lower respiratory illness, dehydration, urinary tract infection and congestive heart failure.   These are excellent tools and can be found at http://interact2.net//tools.html.  The SBAR tool is another tool offered by INTERACT and is an excellent resource for communicating clearly to a physician when there has been an acute condition change identified that warrants notification of the physician.

Finally, I would also like to offer some thoughts about Palliative Care and hospital readmissions.   Residents who are at high risk of actively entering the dying process should also be identified—not only do residents who are often transferred to the hospital during the last days and weeks of their lives impact hospital readmissions, hospitalization can be traumatic and negatively impact the care and well-being of both the resident and their family members during this time.  Consider advance care planning communication with residents and family members to document clearly their wishes for end of life care.  This communication should occur long before the active dying process begins if at all possible as residents and family members often make quick decisions related to their care if they have not clearly thought about what impact aggressive care measures can have during end of life.    Communication with the physician, resident and family members should include clearly defining care approaches as palliative vs. curative and can be helpful in resident and family member’s decisions regarding their development and implementation of advance care directives.