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45% of medication errors occur at a point of transition in care. What can I do to enhance care transitions as we prepare for PDPM?

The American Geriatric Society defines a care transition as “A set of actions designated to ensure the coordination and continuity of health care as a patient transfers between locations and encompasses both the sending and receiving aspects of the transfer”. Poor or ineffective transitions can be detrimental to the resident and negatively impact SNF metrics such as census and quality measures. As we prepare for PDPM, now is the time for SNFs to internally examine their processes for both upstream and downstream care transitions for efficiency, thoroughness and efficacy.

Characteristics of a solid care transition

  • Involving the entire continuum

  • Engaging the resident and caregivers

  • Assessing risk for readmission

  • Following a standardized procedure

  • Planning timely follow-up post-discharge

  • Performing root cause analysis on all readmissions

Key considerations for an effective care transition

When developing your standardized procedure for care transitions, be sure your process takes all key areas into consideration.

  • Include a thorough pre-admission screening to gather all data which will be necessary under PDPM

  • Identify ALL patient needs before admission

  • Determine if your SNF is capable of meeting those needs effectively and cost efficiently

  • Decide if your SNF has the clinical capabilities to achieve the desired outcomes

  • Identify new data points that will impact reimbursement under PDPM that may not have influenced payment under RUGs

  • Begin discharge planning at admission

  • Reassess discharge plan and progress daily

  • Include downstream partners in discharge planning

  • Evaluate clinical and financial outcomes for each resident

  • Implement change based on these evaluations

Remain successful under PDPM

In an era of value-based purchasing where SNFs are now financially penalized for readmissions and under laser focus to condense length of stay while still achieving excellent outcomes, the care transition process is critical for success. Evaluate and redefine care transitions across the continuum in order to be clinically and financially successful under PDPM.

Learn more about redefining care transitions

Do you want to lean more about redefining your care transitions from pre-admission to post-discharge? Watch the latest webinar by clicking below.

Written by Caryn Enderle, MA, CCC, SLP

Director of Business Development



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