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Palliative Care in Nursing Homes

Next Reply: Re:Care Transition Communication Tool
Previous Message: Starting a new program

Post Care Transition Communication Tool
Author: sduross
Date: Sep 9, 2008 10:54 am
I am the director of an inpatient scatter bed Palliative Care program, and we are interested in implementing the use of a form to communicate our assessment, interventions, and care plan changes to the nursing home and the primary doctor when a patient is discharged. Rather than re-invent the wheel, does anyone use a form such as this and would you be willing to share?
Thanks for any feedback.
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Re:Care Transition Communication Tool (by SharolHerr on 09/22/2008)
There are two important points to remember when transferring information; what are the tools that already exist in the inpatient setting and what are the needs of the facility. Forms can be part of the transfer of information but we also find that one on one physician contact with the receiving physician at the facility can be even more effective. At our institutions we use the standard "Continuity of Care" documents and make sure we include salient points such as DNR, symptom management medications, instructions for changes in condition, hospice or therapy needs, etc. We have found that keeping in mind the constraints of the facility is also important such as not using range orders, being aware of formulary at the facility, minimizing IV meds and making sure that the facility has RN coverage 24/7 if IV meds are ordered, providing plan of care to director of nursing for review if needs are going to be complex or if special equipment or services will be required, etc. We also have a copy of the H/P, labs, etc. sent to the facility and discharge summaries are copied to the attending. I don't have one form to do that all but that sounds like a great idea. Sharol Herr, RN, MSEd, CHPN; Nurse Clinician/Education Coordinator; Mount Carmel Health Palliative Care Leadership Center; Columbus, Ohio.

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