Problem Addressed

Transitions from inpatient care to post-acute services have the potential to introduce patient safety issues due to breakdowns in communication between providers and incomplete transfer of information regarding treatment plans and medications. This is particularly true for frail individuals or for those with cognitive impairment who cannot play an active role in the discharge process. As a result, older adults transferred to skilled nursing facilities (SNFs) are at a high risk of mortality and readmissions.¹ The ECHO-Care Transitions (ECHO-CT) innovation sought to address communication gaps between the hospital and the SNF providers when patients transition from the inpatient hospital setting to a SNF, with the objective of promoting safe and effective transitions for complex older patients.

Description of the Innovative Activity

Using videoconferencing, multidisciplinary teams in SNFs participating in ECHO-CT are connected with a hospital-based multidisciplinary care team. The multidisciplinary team at the hospital includes a physician facilitator, pharmacist, social worker, and program administrator. The primary care provider, discharging attending physician, subspecialists, and residents are also invited to participate. At the SNFs, teams include physicians, nurse practitioners, physical therapists, social workers, and case managers. The teams meet weekly to discuss all patients discharged from the hospital that week, and conversations focus on medication reconciliation, critical labs and imaging, discharge follow-up, and case management issues. Prior to the videoconference, the SNF staff fax each patient’s medication administration record to the innovation administrator at the hospital to allow the hospital pharmacist to perform medication reconciliation by comparing discharge medication lists to SNF-administered medication records.²  Discussions between the teams include summary of the patient’s hospital care; an update on the patient’s current condition; a review of medications; and discussions of the ongoing care plan, including any challenges. The goals of these meetings are to improve communication and support cohesive, continuous care.²

Context of the Innovation

The innovation expands on the Project Extension for Community Healthcare Outcomes (ECHO) that began in 2003 at the University of New Mexico. Project ECHO uses videoconferencing to connect rural providers with subspecialists at the academic medical center to improve care delivery in remote locations. There are now ECHO programs in over 60 disease areas across the United States and in other parts of the world.

Following a successful pilot test of this innovation with six SNFs partnered with an academic medical center hub, in 2018 Beth Israel Deaconess Medical Center (BIDMC) received a three-year Agency for Healthcare Research and Quality (AHRQ) grant to expand the program to include not only additional SNF sites, but also to add a community hospital as a hub site. The core components of the innovation remain the same across the academic institution and the community hospital, and a quarterly facilitator feedback process ensures that sites are adhering to the intervention processes. However, the ECHO-CT program staff at BIDMC recognize that resources are likely more limited for the community hospital. As such, while there may be a dedicated staff member for each of the multidisciplinary roles on the team at the academic medical center, these roles may be shared by multiple individuals at the community hospital. Additionally, the volume of patients seen by each SNF associated with the community hospital may be higher, as there are fewer SNFs available for the hospital to discharge to than there are for the academic institution.

Results

Data analysis for the implementation of ECHO-CT was conducted at the level of the SNF as well as at the patient level. Implementation of ECHO-CT is associated with a lower rate of hospital readmissions (P = 0.034), reduction in SNF length of stay (P = 0.01), and significant savings for 30-day total healthcare costs.¹ The types of medication discrepancies resulting from care transitions that were identified through the hospital pharmacist medication reconciliation included prescribing errors (e.g., dosing errors, addition of an inappropriate medication, omission of a medication), monitoring errors, and missed opportunities for optimizing therapy.² The conversations facilitated by the innovation allow for the identification of these discrepancies and provide an opportunity for the pharmacist to issue the SNF with mitigating recommendations.²

In addition to these findings, ECHO-CT participants noted that they found ECHO-CT helped to ensure the quality of patient care and that the structure of the innovation was effective and not overly time- or work-intensive.² Finally, the ECHO-CT research team was able to use data collection from the innovation to generate findings regarding the types of care transition events detected during the sessions between the hospital and SNF. They found that the majority of transition of care breakdowns involved discharge communication or coordination errors (41.7%) or medication issues (37.4%).³

Planning and Development Process

The BIDMC ECHO-CT innovation team encourages interested institutions to work with their existing network to connect to SNFs or hospitals that may be interested in participating and recruiting directly from those sources. Engaging directly with the executive leadership helps to ensure support. Additional key steps include core program planning, such as creating a budget and securing the necessary funding, as well developing the program design, including the development of the evaluation plan and creating program processes and resources.

Additional information to guide interested sites can be found in the ECHO-CT Program Toolkit.

Resources Used and Skills Needed

BIDMC recommends interested sites confirm they have the following in place to support successful implementation:

• Ensure that both the hospital and the participating SNFs have the technology necessary for teleconferencing, and particularly that they have the ability to connect via video. BIDMC conducted a technology run-through with the participating SNF information technology departments prior to beginning implementation and provided SNFs with webcams whenever necessary.  
• Identify one or two individuals who can serve as the primary point (or points) of contact at each site. Responsibilities primarily include confirming which patients are to be discussed during the weekly meetings, gathering and sending patient medication lists to the hospital hub each week, and ensuring that the rest of the team joins the weekly call. The SNF and hospital are responsible for identifying these individuals, but the role is often filled by floor nurses.
• Identify individuals to serve in key innovation clinical roles. These roles and responsibilities can be shared by multiple staff members if staff bandwidth is too limited for any one person to take on all responsibility.  

BIDMC has also developed resources for facilities to use, including case study presentations, prescribing information, an ECHO-specific process guide and intake form, and a program toolkit.

Getting Started with This Innovation

BIDMC held a half-day orientation session with all participating SNF partners as a core component of staff training. A copy of the PowerPoint slides shared during this orientation can be accessed for free in the program toolkit. The session included:

• A discussion and review of why the initiative is important to patient care
• A mock session of the program weekly call
• Outline of participating expectations and roles in the project

In addition to training, all other program resources should be distributed to participating staff at this time. Once program implementation has begun and weekly videoconferences are underway, data collection should commence and SNFs should be surveyed regarding their satisfaction with the support they are receiving from the hospital teams.

Sustaining This Innovation

BIDMC has achieved 100% retention of SNFs participating in the initiative and credits this success to ongoing engagement with the SNFs. This has included quarterly education sessions that allow the SNFs to interact with each other, share best practices and ideas, and discuss pertinent issues; a quarterly newsletter that profiles different SNFs and their staff; and a biannual SNF survey asking what the staff members like about the program, what could be improved, and what could be simplified.

References/Related Articles

• Moore AB, Krupp JE, Dufour AB, et al. Improving transitions to postacute care for elderly patients using a novel video-conferencing program: ECHO-Care Transitions. Am J Med. 2017;130(10):1199-1204. PMID: 28551043. (PDF)
• Farris G, Sircar M, Bortinger J, et al. Extension for Community Healthcare Outcomes-Care Transitions: enhancing geriatric care transitions through a multidisciplinary videoconference. J Am Geriatr Soc. 2017;65(3):598-602. PMID: 28032896. (PDF)
• Gonzalez MR, Junge-Maughan L, Lipsitz LA, Moore A. ECHO-CT: an interdisciplinary videoconference model for identifying potential postdischarge transition-of-care events. J Hosp Med. 2021;16(2):93-96. [Access]

Footnotes

1. Moore AB, Krupp JE, Dufour AB, et al. Improving transitions to postacute care for elderly patients using a novel video-conferencing program: ECHO-Care Transitions. Am J Med. 2017;130(10):1199-1204. PMID: 28551043. (PDF)
2. Farris G, Sircar M, Bortinger J, et al. Extension for Community Healthcare Outcomes-Care Transitions: enhancing geriatric care transitions through a multidisciplinary videoconference. J Am Geriatr Soc. 2017;65(3):598-602. PMID: 28032896. (PDF)
3. Gonzalez MR, Junge-Maughan L, Lipsitz LA, Moore A. ECHO-CT: an interdisciplinary videoconference model for identifying potential postdischarge transition-of-care events. J Hosp Med. 2021;16(2):93-96. [Access]

Date Verified by Innovator

May 17, 2021