presented by Cathy Wollman
Financial: Cathy Wollman receives compensation from MedBridge for this course. There is no financial interest beyond the production of this course.
Non-Financial: Cathy Wollman has no competing non-financial interests or relationships with regard to the content presented in this course.
Satisfactory completion requirements: All disciplines must complete learning assessments to be awarded credit, no minimum score required unless otherwise specified within the course.
Cathy Wollman, DNP, RN, GNP-BC, CRNP
Dr. Wollman has been an educator and clinician for more than 35 years. She has worked as a gerontologic nurse practitioner at multiple sites of care across the health care system. She also served as director of senior health for a large health system and the coordinator of the nurse practitioner program for more than…Read full bio
1. Introduction to Transitions of Care For SNF Residents
This chapter will define transitions of care and their effect on residents at the time of admission to the SNF and subsequent transitions, including discharge to home. Barriers to effective transitions and statistics that characterize the complex and challenging aspects of transitions of care in the SNF will be reviewed. Common high-risk characteristics of SNF residents that make them susceptible to poor outcomes will be discussed.
2. Resident and Family Engagement for Safe Transfers of SNF Residents
This chapter will discuss the need for person-centered care, communication and safety during transitions of care. The focus of the chapter will be on transition planning, essential information that supports quality transfers, and the requirements for education and engagement of the resident and family during transitions. The role of the enhanced interprofessional team in the transitions of care process will be evaluated. Participants will have an increased awareness of the need for ongoing assessment, communication, education, and documentation for high-risk residents.
3. Healthcare Provider Engagement For Safe Transfers Of SNF Residents
This chapter begins with a discussion of safe medication reconciliation. Additional focus is on essential follow-up care and the roles of each health-care provider in quality transitions of care. Requirements for enhanced communication between sites of care and roles of accountable clinicians is emphasized. Evidence-based models of transitions of care are included. The goals of patients and families will be highlighted as part of the plan of care.
4. A Case Study Of The Typical High-Risk Resident
This chapter presents a case study of a typical high risk resident admitted to the SNF. The focus will be on comprehensive person-centered care, communication and safety. The case will synthesize the Part I discussion of evidence based transitions of care.