Background: Medically complex patients discharged from hospitals to skilled nursing facilities (SNFs) are at high risk for unintentional errors, re-hospitalization, and mortality. Commonly reported transitional care errors include poor communication of critical information, limited access to medical records, and lack of clarity as to follow-up plans or patients care goals. Telehealth is increasingly used in healthcare, especially in triage and specialty consultation.
Purpose: We sought to improve the quality of transitional care from hospital to SNF through the development of a weekly multidisciplinary telehealth video conference. We hypothesized that these video conferences would allow for communication between hospital and SNF teams about patients transitional care needs, and would decrease medication errors. We also logged issues uncovered through the teleconference as areas of focus for future quality improvement work.
Description: We implemented a weekly multidisciplinary telehealth video conference between our hospital and 3 local skilled nursing facility (SNF) clinical teams to discuss all patients discharged to these facilities in the prior week. Conferences prioritize systematic patient discussion of transitional care pillars such as medication reconciliation, laboratory follow-up, patient-specific disease management, and advanced care planning. Hospital medicine providers review patients prior to the conference, and pharmacists perform medication reconciliation across the patients’ home, hospital discharge, and current SNF medication lists. Each patient is discussed for approximately 8 minutes, conferences last 120 minutes or less. We discussed 193 patient transitions during 19 telehealth conferences. Pharmacists identified at least one medication error on the SNF medication list in 57% of transitions reviewed (23% of errors were serious, 49% significant). Systems issues identified during the conferences were recorded and categorized into medication related, durable medical equipment (DME) related, or communication related. 204 errors were identified due to missing or incorrect information included on the discharge instructions. Of the 204 errors identified, 41% (n=84) were related to medications (e.g. missing stop dates, incorrect weight-based or renal dosing), 4% (n=9) to DME (e.g. incomplete or absent directions for use), and 54% (n=111) to communication. Whereas 68% (n=76) of communication errors were related to medications or DME equipment, 32% (n=35) were exclusively communication errors (e.g. code status discrepancy, missing referral appointment information, or Foley catheter instructions).
Conclusions: Multidisciplinary telehealth video conferences are feasible and beneficial in building clinical partnerships between hospital and skilled nursing facility teams. Through these video conferences, teams can efficiently identify and mitigate transitional care errors and omissions in discharge documentation and formulate patient care plans for subsequent treatment and follow-up. Pharmacist expertise in medication reconciliation and optimization is integral. Unfortunately, occurrence of communication and medication errors is high. These identified errors are important targets for future system wide care transition improvement strategies. Future study is needed to understand impact on readmissions and healthcare utilization.