Lack of adequate continuity of care at discharge has been identified as a factor for frequent readmissions from Extended Care Facilities (ECFs). Older adults with chronic conditions hospitalized and subsequently discharged to ECFs represent a particularly vulnerable population. (Jacobs 2011).
Review of hospital cases in 2011 revealed that over 20% of patient discharged to ECFs, were readmitted within 30 days. Readmissions from ECFs are a hardship for patients, are costly for institutions, and reflect fragmentation of care across the continuum.
The LINCT (Liaison In Nursing Care Transitions) Program Initiative is a nurse-driven organizational partnership with ECFs to ensure continuity of quality outcomes during transition between the hospital and extended care continuum.
- Reduce 30-day readmissions and hospital length of stay for patients discharged to partner LINCT facility.
- Increase satisfaction of patient/family with discharge process and transition of care across the continuum.
- Increase satisfaction of staff, physicians, and ECFs with discharge and transition process.
Methods and Intervention:
- Formal affiliation agreement established with high-volume ECFs to participate in the LINCT Program.
- Dedicated acute nurse to serve as liaison between hospital and LINCT facility.
- Pre-discharge hospital rounding, collaboration with inter-professional team, and readmission risk assessment on patients transitioning to LINCT facility.
- Education/support for patients/family members preparing for transition.
- Post-discharge rounding on high-risk patients admitted to LINCT factility within the first 24-72 hours.
- Education for ECF staff on topics relevant to care of patients with chronic conditions.
- Monthly inter-professional LINCT quality review meetings at ECF site.
Outcomes and Implications:
- Data reflect dramatic reduction of readmissions from partnering facilities.
- Satisfaction reported by partnering ECFs, patients, and physicians.
- Program expanding to include additional ECF partners and rapidly evolving as an essential component in the organization’s Integrated System of Care development plan.