Building an Integrated System of Care Across the Extended Care Continuum with the LINCT Program (Liaison In Nursing Care Transitions)

Problem:

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. 

Approach:

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.

Objectives: 

• 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:

1. Data reflect dramatic reduction of readmissions from partnering facilities.
2. Satisfaction reported by partnering ECFs, patients, and physicians.
3. Program expanding to include additional ECF partners and rapidly evolving as an essential component in the organization’s Integrated System of Care development plan.