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Evaluation

Interdisciplinary Team (IDT)

(MO16) Revisiting an Interdisciplinary Intervention to Reduce Readmissions to Hospital from PALTC Facilities

Monday, March 11, 2024
2:00 PM – 3:00 PM CT
Room: 302
CMD Management Credit Recording
CME: (1) MOC: (1) CMD Management: (1) NP Pharmacology Hours (.25)

    Session Chair/Speaker(s)

  • Edward D. Gometz, MD

    Assistant Professsor of Medicine
    Rush University Medical Center
    Chicago, IL

    Disclosure(s): No financial relationships to disclose.

    • Speaker(s)

  • MB

    Magdalena Bednarczyk, MD

    Division Chief, Geriatric Medicine and Palliative Care
    Rush University Medical Center
    Chicago, Illinois

    Disclosure(s): No financial relationships to disclose.

Disclosure(s):
Edward D. Gometz, MD: No financial relationships to disclose.
Magdalena Bednarczyk, MD: No financial relationships to disclose.
We will revisit an innovative interdisciplinary transition of care model that we originally presented the AMDA Annual Meeting in 2020. Our original intervention increased provider presence at SNF, created monthly readmission meetings between stakeholders, involved a transition of care evaluation prior to discharge to SNF. The invention decreased SNF to hospital readmission rates from 30% in 2017 to 11.7% in 2018-2019. Post pandemic, our intervention needed to adapt to the new challenges facing PALTC facilities. Although our readmission rates did rise due to COVID, our fidelity to following patients through their continuum of care improved and led to dispositions to more appropriate levels of care, incorporating a 4Ms framework. This presentation will describe how the intervention has evolved and now includes a multidisciplinary consult service aimed at improving complex transitions of care among our highest risk patients.

Learning Objectives:

At the completion of this session, learners will be able to:
  • Discuss lessons learned in the process of changing from our former practice model to an innovative, interdisciplinary transition of care model that has improved readmission rates from SNF.
  • Describe use of an innovative communication method via a HIPAA-compliant texting app that includes multiple stakeholders. This allows for timely communication of a patient’s medical needs, discharge planning, and a geriatric-focused clinical hand off to the receiving team at the SNF.
  • Discuss the benefits and challenges of an innovative consult team focused on addressing the multidisciplinary needs of patients facing complex transitions of care.
  • Explore ways to implement elements of this intervention in other health systems and describe ways to incentivize stakeholders to participate in this multidisciplinary model.