If you’re looking to improve care transitions for residents in your facility, you’ll be delighted to know that there’s a new toolkit that you can add to your knowledge and practice arsenal.
The American Medical Directors Association (AMDA) recently released a Clinical Practice Guideline, entitled “Transitions of Care in the Long-Term Care Continuum.” This treasure trove of tools, advice and resources focuses on best practices when transitioning care within a care setting, between care settings, across care levels, and across health care providers.
The guideline also offers seven steps to implement an effective care-transition program:
1. Identify when a resident has a recognized status change.
2. The interdisciplinary team members communicate with each other and with the patient/family (unit of care) to determine the most appropriate care transition.
3. The sending facility or care entity communicates with the receiving entity. The receiving entity must have the patient information prior to patient arrival.
4. The patient is physically handed over to the receiving level or setting of care.
5. Both sending and receiving entities verify that the patient has been handed over and that essential patient information has been received.
6. The sending facility follows up to confirm that the patient has been successfully transitioned to the new level or setting of care.
7. Monitor the facility’s performance in managing care transitions.
Resource: To download the entire Clinical Practice Guideline, go to www.amda.com/tools/clinical/toccpg pdf.
Watch for Changes to Key RAI Contacts
On Aug. 20, the Centers for Medicare & Medicaid Services (CMS) issued an update of Appendix B to the RAI Manual. The update, officially dated Aug. 18, contains changes to the list of state RAI coordinators, MDS automation coordinators, RAI panel members, and regional office contacts.
Link: To view the updated Appendix B, go to www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Downloads/MDS-RAI-Manual-Appendix-B-8182014.pdf.
Study 20 Revised Interpretive Guidelines’ F-Tags
On July 3, CMS revised the Interpretive State Operations Manual Guidelines, as well as the Investigative Protocols for these F-Tags:
CMS revised these F-Tags as needed to incorporate survey and certification policy memos issued from October 2003 through May 2014, explained Evvie Munley, senior health policy analyst for Washington, DC-based Leading Age, in a July 9 analysis.
Link: To read the entire S&C memo (S&C: 14-37-NH), go to www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-14-37.pdf.