Enhancing the referral process between a hospital and SNF: how information technology speeded and simplified referrals for two organizations.

To tackle the age-old problem of improving referrals between acute-care hospitals and post-acute nursing homes, two organizations have created an innovative system to improve their communication.

NHC Fort Sanders, a 172-bed SNF, is one of 78 centers operated by National Health Care (NHC), NHC also operates 32 home-care agencies, 21 assisted living centers, and 7 independent living centers. Fort Sanders Regional Medical Center is one of five hospitals in the Covenant Health system. The two organizations, both based in Knoxville, Tennessee, entered into a joint ownership/partnership arrangement in 1997 involving the SNF and hospital.

The advent of the Medicare PPS and more recent implementation of various HIPAA rules have had a major impact on the referral process. The traditional faxing of medical records from the hospital to the SNF, for example, raised issues of patient confidentiality under HIPAA. Ineffective use of discharge planners' time in copying medical records, faxing, and calling admissions coordinators further directed attention to the referral process. Two basic changes were implemented: use of a PC connected to the hospital's health information network for the transmission of full medical records, and the use of an alpha paging system (explained below) to alert referral coordinators regarding admissions and discharges.

In the past, the discharge planner would make a copy of the patient's medical record and fax it to the SNF--not a time-efficient task for someone who, more often than not, has a master's degree. Then the discharge planner would call the nursing center's admissions coordinator, often requiring multiple attempts. The advent of voice mail helped, but not enough.

The answer to improving this process was using a PC and establishing connectivity between providers. Specifically, the solution involved:

* The hospital placing a PC and printer in the nursing center's admission coordinator's office. No special software was required. Use of an Internet browser and controlled access to the hospital network (intranet) were key elements. (The proprietary relationship between the hospital and nursing home increased the comfort level concerning intranet access.)

* Assigning confidential log-in IDs and passwords to three SNF personnel--the admissions coordinator, the assistant DON, and the assistant administrator--allowing them access to the hospital's medical records of patients being referred.

* Requiring the hospital discharge planner to release the patient's medical record electronically to the nursing center prior to the referral. (This access is limited to 72 hours postdischarge.)

* Making readily available lab results, history and physical, therapy notes, medications, radiology reports, and more. Physician notes are not available at present because they are not electronically charted; they are still faxed.

* Receiving authorized release of personal health information (PHI) via power of attorney or other form of patient permission.

* Printing the medical information for review by the DON, who determines the facility's ability to meet the patient's clinical needs.

With this amount of clear, concise, complete information so readily accessible by the responsible parties, improving communication among them became a principal focus. Enter, the alpha paging system, which uses text messaging via a Motorola Alphamate II pager, the Internet, or a software program; the SNF and hospital chose the Alphamate. This required both entities to place a small keyboard in a central location and have each discharge planner and the admissions coordinator carry a pager. A dedicated phone line installed at the nursing center.

This method differs from digital paging because it eliminates having to call back the number received on the pager. One simply reads the message on the pager, which holds 80 characters, or about 16 words. When the discharge planner sends a text message alerting the admissions coordinator to the release of a record for review and possible admission of the patient, the admissions coordinator can review the record online. After review, the DON can accept the admission via paging. A follow-up call can be coordinated for communicating specifics of the transfer, such as scheduling ah appointment with the family to complete admission paperwork.

Besides the benefit of having complete medical information readily available to admissions coordinators, the PC/alpha pager combination enhances the SNF staffs ability to complete the MDS. Medicare allows the SNF to use information gathered from the last tire days of a hospital stay to compile the MDS assessment, thus improving accuracy in determining the RUG reimbursement level.

The principal beneficiary, however, is the patient, who can be better assured that providers are working with PHI that is accurate, complete, legible, and secured, enhancing the chances of good decision making.

Douglas S. Ford, HS, NHA (Fellow), is administrator of the NHC Fort Sanders skilled nursing facility in Knoxville, Tennessee. To comment on this article, please send e-mail to [e-mail].