Seniority Inc., a management company based in Addison, Texas with six continuing care retirement communities (CCRCs), hired transitional care registered nurses (RNs) for the facilities in 2016, according to Skilled Nursing News.
The transitional care RN’s entire role is to follow patients after discharge to the home, tracking them for at least 30 days regardless of payor, Misty Miller, vice president of clinical services at Seniority, told Skilled Nursing News.
This can entail a variety of steps, including ensuring the resident has filled their medications, making sure that residents understand how to take those medications, or ensuring that durable medical equipment (DME) or home health services arrives in a timely fashion. The transitional care RNs start seeing the patients when they enter the skilled nursing setting and also attend discharge planning care conferences.
Seniority discharges, per community, approximately 12 to 15 SNF patients monthly, Miller said. All six CCRCs, which have 309 skilled nursing beds between them, saw a decrease in readmission rates to the hospital, with a combined rate of 13% in 2017. There have also been anecdotes of the transitional care nurses being able to intervene for residents in time to prevent hospital readmissions, though there’s no hard data for such preventions, Miller said.
The company is now looking to add to the program by adding a focus on transitions of care from skilled nursing to the hospital. Starting Jan. 1 of this year, the transitional care RNs spend more time with and assess residents in skilled nursing, looking specifically for changes that could cause the residents to be rehospitalized. It also will be implementing a new software program aimed at preventing readmissions.
Read the full story at Skilled Nursing News.