Rural hospital transitions in care improves patient satisfaction

Purpose:
To provide our patients with a safe discharge transition plan based on call back and discharge satisfaction data.

Significance:
rural hospitals have limited resources internally as well as within the communities they serve. Identifying high risk patients early and implementing a multidisciplinary discharge plan with call back process will improve patients success at discharge.

Strategy and Implementation:
Case management is the navigator for hospitalized patients. A policy was created to focus on 5 high risk areas including care, skill,medical, social and financial and each area has a map of how to utilize community resources at discharge. the case manager uses a multidisciplinary approach to identify needs early and meet the needs prior to discharge then call back the patients to determine effectiveness of the discharge plan and learn from discharge failures. Checklist communication for frontline staff to align their DC processes with community resources. Daily huddles with casemanager, UM, MD and quality supervisor to establish plans for patients. Patient/caregiver involvement in plan of care.

Evaluation:
Patient satisfaction scores for discharge process increase from 50 to 60 % to consistently > 90%. improved readmission rates Streamlined processes to prevent last minute scrambling to discharge Staff engagement scores improved

Implications for Practice:
Interdisciplinary approaches Call back process Policy creation Checklist Huddles