Assessment

It is common for older adults in skilled nursing facilities (SNF) or residential facilities to experience acute medical problems that lead them to access the health care system through the emergency department (ED). This transition of care for the older adult contains inherent and added challenges and potential dangers.

Potential Challenges Encountered During SNF to ED Transitions: Internal and external factors may both contribute to challenges during care transitions for older adults.

1. Factors that are internal to the patient may include:

• Many complex and possibly interacting co-morbid illnesses
• Multiple medications
• Patient difficulty in providing information and history due to dementia or acute illness
• Uncertainty of patient goals of care and identification of any surrogate decision-makers

2. Factors that are external to the patient may include:

• Inadequate time at the SNF to prepare patient care and history documents prior to emergent transfer
• Information loss due to multiple points of information transfer (e.g. from SNF to EMS to ED intake to ED care team)

3. These time factors and multiple transition of care episodes may lead to difficulty in obtaining adequate history (e.g. reason for patient transfer, acuity verses chronicity, what interventions have already been tried), and a lack of information regarding the patient’s baseline health, cognition and functional status. 

• Inadequate knowledge of the referring SNF
  • The ED team may not understand what care levels each facility can provide and where in the facility an individual resides.   

Opportunities for Improvement During SNF to ED Transitions:

• Opportunities to improve care after the transition of an older adult from a SNF to the ED can be found both in improvements and changes made by systems and through the practice change of individual providers.

Systems-based Practice Improvements in SNF to ED Transitions:

• Design a process for “warm handoff” verbal communication:
  • Consider phone conversations between the SNF provider and the ED provider prior to, or just after patient arrival in the ED, and again just prior to return transfer to the SNF at ED discharge.  Frame the ED transfer as an “ED consultation” with specific questions asked to clarify goals and purpose of care.

• Include Emergency Medical System (EMS) providers in communication and care.  These essential team members play a key role in connecting the patient from the SNF/residential facility to the ED. For the individual ED provider, discussing the presentation with EMS bedside upon ED arrival reduces the risk of faulty communication. Providers may also work with EMS personnel to educate and encourage them to gather valuable information at the facility. 
• Identify an inter-disciplinary team (e.g., care providers, social workers and administrators) from both the hospital and facility to design the care transition process (in both directions) and track outcome metrics as the process evolves.
• Educate ED staff and providers about types of long-term care facilities and diagnostic and treatment capabilities available at the referring facilities. 
• Create a standard transition document and process for transfer to and from ED, in collaboration with local SNF administrative leaders and EMS leaders. 

Individual-based Practice Improvements in SNF to ED Transitions:

• Ensure that the patient, family, and/or caregiver are as comfortable as possible during this vulnerable situation.
• Review vital signs and recent changes.
• Check with the patient about their chief complaint as they may be able to accurately provide information
• Review:
  • Advance directives and goals of care with the patient, family and the power of attorney for health care, as appropriate.
  • SNF transfer form, looking for the specific reason for the transfer as well as what care was provided prior to the transfer.
  • Baseline cognitive and functional status, as well as recent changes from baseline.
  • Co-morbid illnesses
  • New diagnoses and any recent hospital discharges
  • Medication list, including “as needed” medications and supplements as well as any recent changes in medications or dosages.