Practice initiative | Description |
EpiCare Link implementation at SNFs | Provided and trained SNF staff regarding access to hospital medical records |
Flagging patients who are high risk | Added a flag within the electronic medical record regarding those patients who have an integrated care manager to enable SNFs to make contact about complex patients |
Flagging patients’ MOLST/HCP status | Added a flag within the electronic medical record regarding those patients with MOLST and HCP documentation completed |
Serious illness checklist conversations | Provided training and launched a serious illness checklist intervention (related to completing serious illness conversations with patients to assess goals of care) |
Outpatient visit SNF coversheet | Established coversheet for SNF patients attending outpatient visits to encourage providers to call, if appropriate, the SNF before sending patients to emergency room for readmission |
HCP, healthcare proxy; MOLST, Medical Orders for Life-Sustaining Treatment; SNF, short-term nursing facility.