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Discharges and Readmissions: Essentials for a Smooth Handover (Enhabit 2024)

presented by Nancy Skinner, RN, CCM, CMGT-RN, ACM-RN, CMCN, FCM and Colleen Morley, DNP, RN, CCM, CMAC, CMCN, ACM-RN

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Disclosure Statement:

Financial: Colleen Morley receives compensation from MedBridge for this course. There is no financial interest beyond the production of this course.

Nonfinancial: Colleen Morley has no competing nonfinancial interests or relationships with regard to the content presented in this course.

Financial: Nancy Skinner receives compensation from MedBridge for this course. She is a consultant/educator at Encompass. There is no financial interest beyond the production of this course.

Nonfinancial: Nancy Skinner has no competing nonfinancial interests or relationships with regard to the content presented in this course.

Satisfactory completion requirements: All disciplines must complete learning assessments to be awarded credit, no minimum score required unless otherwise specified within the course.

MedBridge is committed to accessibility for all of our subscribers. If you are in need of a disability-related accommodation, please contact [email protected]. We will process requests for reasonable accommodation and will provide reasonable accommodations where appropriate, in a prompt and efficient manner.

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Video Runtime: 39 Minutes; Learning Assessment Time: 35 Minutes

Gaps in the transitional care process may escalate when a patient is discharged from a structured environment of care to their home or other community site of care. These gaps may contribute to the development of negative healthcare outcomes that might be a direct cause of a readmission to acute care. Although the rates of hospital readmissions have diminished slightly since 2014, the Centers for Medicare & Medicaid Services (CMS) will penalize more than 2,500 hospitals in fiscal year 2021 for readmission rates that exceed national averages. In addition to readmissions associated with a discharge from an acute care hospital, CMS has developed specific quality measures for post-acute care that focus on potentially preventable readmissions during the post-acute stay and following discharge from the post-acute facility. Closing these gaps is vital to balancing patient advocacy and fiscal accountability.

Studies have demonstrated that a majority of negative outcomes and serious medical errors are associated with communication gaps occurring during care transitions. This course will focus on the development of specific initiatives employed by the transdisciplinary team to support effective communication strategies as the patient transitions to the next level of care and the next setting of care. This course is applicable to physical therapists, occupational therapists, speech-language pathologists, nurses, social workers, and case managers.

Meet Your Instructors

Nancy Skinner, RN, CCM, CMGT-RN, ACM-RN, CMCN, FCM

Nancy has, for the past 30 years, served as a case manager, director of case management, and international case management educator. In her current role as principal consultant for Riverside HealthCare Consulting, she advances programs that promote excellence in care coordination and other transitional care strategies. She has presented more than 400 on-site programs and…

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Colleen Morley, DNP, RN, CCM, CMAC, CMCN, ACM-RN

Dr. Colleen Morley has held positions in acute care as director of case management at several acute care facilities and managed care entities in Illinois, overseeing utilization review, case management, and social services for more than 12 years and piloting quality improvement initiatives focused on readmission reduction, care coordination through better communication, and population health…

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Chapters & Learning Objectives

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1. The Transitional Team

In this chapter, the discussion centers on the identification and definition of key roles on the care coordination team, with emphasis on the value of these relationships and fostering collaboration to create a patient-centered care experience. We look at the difference between interdisciplinary and transdisciplinary teams and the need to eliminate silos.

2. Changing a Handoff to a Handover

We continue the discussion with a comparison between handoff and handover in transition management. Communication across the varied transitional points is vital to the success of the patient, both in sending and receiving information. This chapter features demonstrations of both good and poor examples of sending and receiving between care team members at a key transition point from acute to post-acute care.

3. Mr. Brown’s Journey to Optimal Health

Using the case study of Mr. Brown, we analyze the original what we know with the sending and receiving model. By digging deeper into both sides, we identify more information needed to ensure that Mr. Brown has a more complete and effective transitional experience.

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