Transfer from the Hospital to a Skilled-Nursing/Long-Term

Transfer from the Hospital to a Skilled-Nursing/Long-Term Care Facility An 85-year-old male had a total-hip replacement, is stable, and agrees to complete his rehabilitation and strengthening at the local nursing home, which has skilled nursing services. The staff nurse prepares the patient for discharge and transfer. The assessments are completed prior to discharge within the hospital EHRS. New electronic prescriptions are sent to the patient’s pharmacy for delivery to the nursing home. The nurse updates the patient’s problem list and adds the problem of risk for falls, and ensures that interventions (e.g., fall prevention, pain management, and exercise promotion) and the current status on patient outcomes for pain and mobility level are up-to-date on the care plan. The nurse contacts the receiving setting and provides the name and other identifying information to the receiving manager or clinical nurse leader. While on the phone, the nurse at the nursing home accesses the state’s information network through a web portal to use a record-locator service to search for the patient. The receiving nurse pulls in the advance directive, the plan of care, the problem list, new prescriptions, and continued medications. The last INR test result was posted this morning with the most recent dose for anticoagulation, which was administered in the morning. The two nurses discuss the plans for the anticoagulant protocol that was ordered by the cardiologist for the patient during the patient’s rehabilitation. Will the long-term care setting be able to use the record-locator service to obtain the information if they do not have a full electronic health record system? How does the nursing home access the patient’s information before arrival? Should the long-term care facility wait to use the state’s health information network after they implement the EHRS? How can the facility receive training? SCIENCE

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