Table 4

Major initiatives implemented as a result of the readmission review

Practice initiativeDescription
EpiCare Link implementation at SNFsProvided and trained SNF staff regarding access to hospital medical records
Flagging patients who are high riskAdded 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 statusAdded a flag within the electronic medical record regarding those patients with MOLST and HCP documentation completed
Serious illness checklist conversationsProvided training and launched a serious illness checklist intervention (related to completing serious illness conversations with patients to assess goals of care)
Outpatient visit SNF coversheetEstablished 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.