MRMC

Pictured are Canaan Watkins, RN, and Theresa Harris, RN, post-acute care education coordinator at Maury Regional Medical Center with NHC-Maury Regional Transitional Care Center Administrator Edward Moore and Kayce Brooks, RN.

Maury Regional Health, in partnership with post-acute care facilities throughout the region, has implemented a technology-based program designed to improve a patient’s transition from an inpatient hospital stay to a post-acute care facility.

The Virtual Transition of Care Program uses teleconferencing technology to conduct face-to-face connections between patients, family members and staff members at the hospital and staff members who are onsite at the post-acute care facility to which they will be transferring. Post-acute care providers may include skilled nursing facilities, inpatient rehabilitation centers or palliative care programs.

“This program has the potential to greatly enhance communication as patients make the transition from an inpatient setting to a skilled nursing or rehabilitation setting,” said Mark Kirschbaum, vice president of population health for Maury Regional Heath. “Our goal is to enhance communication, quality of care and patient safety on both sides of the transfer process.”

Before a patient is transferred from the hospital to a post-acute care facility, a nurse will use a tablet in the patient’s hospital room to remotely connect with staff members at the receiving facility. This virtual meeting provides an opportunity for staff members at both facilities to review the patient's transfer report and other important information.

The patient and family members are encouraged to be involved in this conversation and ask questions about the plan of care and what to expect in the post-acute care setting. Once all questions have been addressed, the virtual meeting will conclude and the transfer will move forward.

According to Kirschbaum, such interactions between hospital and post-acute care teams provide a variety of opportunities, including:

· Collaboration to ensure patients are admitted to the appropriate level of care

· Visual assessment of a patient prior to transfer and admission

· Improved communication of vital information to support patient management

· Engaged patients and families who better understand and are acquainted with the post-acute care team

The Maury Regional Health Post-Acute Care Network is composed of members who meet defined criteria related to patient care and outcomes. Goals of the network include improved quality of care, clinical outcomes and care coordination.

The new transition program is currently available for patients who are discharging from inpatient units at Maury Regional Medical Center for transfer to NHC Maury Regional Transitional Care and Lifecare. This program will soon expand to the post-acute care facilities of Lewis County Nursing Home, Magnolia Healthcare, NHC HealthCare Columbia, NHC HealthCare Oakwood (Lewisburg), NHC Lawrenceburg, NHC Lewisburg, NHC Pulaski and NHC Scott (Lawrenceburg).

“Within a few months, we expect virtual hand-offs to be available to all patients leaving Maury Regional bound for any of our partnered community post-acute care network facilities," Kirschbaum said. "We also hope to accommodate linking-in family members who cannot be physically present for the transition meeting."