by Deborah Wolff-Baker MSN, ACHPN, FNP-BC, GS-C

The November 3rd CALTCM Fall Meeting, Reducing Readmissions Through Better Transitions,  was held at the Betty Irene Moore School of Nursing at UC Davis. This was a unique day in CALTCM history, highlighting not only ways to reduce readmissions through better transitions, but a blooming partnership between CALTCM and the Northern California Chapter of the Gerontological Advanced Practice Nurses Association (NCCGAPNA).

The day began with a keynote talk by Dr. Terry Hill on the hidden burdens of community long-term care provided by family caregivers.  The rest of the morning was packed full of information to educate and inform attendees about issues associated with community discharges and transitions of care with an emphasis on upstream thinking to prevent avoidable hospital readmissions. This information was presented in symposium style with 5 expert Nurse Practitioner members of NCCGAPNA speaking from the perspective of home-based palliative and primary care providers who provide medical care to patients discharged from Skilled Facilities into the community.

Content included Jennifer Serafin and Patricia Kenny’s discussion of what is and is not appropriate for patients being discharged to Assisted Living Facilities and what issues, including regulatory issues, should be considered during the discharge planning process to promote a safe and seamless discharge that assures the patient or resident is actually appropriate for discharge to an Assisted Living setting.  Ron Ordona presented the audience with his doctoral research on reducing polypharmacy in patients across transitions of care, medication safety and medication issues to consider in patients discharging from Post-Acute facilities. Deborah Wolff-Baker presented the concept of skilled facilities partnering with nurse practitioners to utilize a Transitional Care Model (such as Naylor’s evidence-based TCM model) to screen and identify high-risk patients before discharge and provide Transitional Care services based on CMS’ Transitional Care Management Services (TCM) 30-day benefit that providers may bill.  (Click here to view the CMS Transitional Care Model Packet)

Other sessions included Mary Cochran-Abraham’s interactive discussion of ways to de-escalate agitation stemming from the behavioral and psychiatric symptoms of dementia with person-centered care and a demonstration of a few of Teepa Snow’s effective techniques to accomplish this. Attendees were able to group together to learn and perform these techniques, including learning how to provide comforting hand-over-hand assistance to patients. Deb Bakerjian presented the components and results of the CAHF Music and Memory Project, involving over 300 NHs in California utilizing a QAPI approach.  The implementation of both these programs and strategies have demonstrated positive effects on the distressing behavior of dementia patients while reducing the use of psychotropic medications and are invaluable aids to SNFs in caring for patients while meeting the mandates for providing person-centered care.  Incorporating SNF 2.0® and Interact tools were discussed by Dr. Albert Lam as an effective way to prevent readmissions in his talk entitled: Six Years of "Modernizing” SNF Care for the 21st Century.

Attendees spent a portion of the afternoon in a uniquely interactive hands-on opportunity to choose one of the conference topics to discuss in further detail in an Action Planning Session with the presenter of the topic. This session was designed to assist attendees to develop a process improvement plan to bring back their SNF for further development and implementation by utilizing the QAPI process. The day ended with important Policy, Regulatory and Legislative Updates to help guide SNF planning and improvement projects.