25% of seniors discharged to a skilled nursing facility are being readmitted to hospital within 30 days. Having a transitional care plan that addresses this issue is critical.
Certified Nursing Assistant identifies a change in the resident's status.
Certified Nursing Assistant (CNR) alerts Registered Nurse(RN) of resident status change.
RN evaluates resident, collects information, and contacts physician.
RN meets with physicians to discuss and determine appropriate care.
By the time the physician can determine care, the resident’s condition has deteriorated.
In order to reduce the potential for hospital readmission, it all comes down to communicating the right information, at the right time, to the right people.
At the bedside, the CNR documents the residents' change in condition.
INTERACT® is used to capture any clinical data needed by RN and physician.
Physician and RN utilize the clinical data in their decision-making process to diagnose resident.
Any modification to the residents' plan of care are implemented and treatment begins at the facility.
By improving the identification, evaluation, and communication on changes in resident status, acute care transfers can be avoided. In fact, transitional care programs have already reduced readmission rates by 45%. So what are you waiting for?