Transcript Shadowing program - Avoid Readmissions through Collaboration

Shadowing program
• The collaborative agreed that a good way appreciate
others viewpoints is to see what is involved with their job.
This allows for understanding and mutual respect.
• Holly Fuscaldo and Kelly Cookson set up the program
• Staff of rehab/nursing home nurses and admission
coordinators followed hospital nurses and case
managers through their morning in the spring.
• In the fall rehab/nursing home nurses and admission
coordinators invited the hospital nurses and the case
manager to follow their morning
Outcomes of the program
• The nurses together determined that nurse to
nurse report would be valuable. This would allow
for a better understanding of the patient that they
would be receiving.
• It would give the nurses a chance to have a
direct communication on a nursing level.
• This provides time to ask questions that would
be valuable to help with smooth transition of the
patient to the next level of care
Outcomes of the program
• SCH added Nurse to Nurse report into the
nursing policy and procedures manual
• Over all it has been well received and has
effectively continued to improve the
communication across settings
• The nurses bonded and reciprocated
attending the facility whom they had been
paired with.
Outcomes of the program
• Allowed staff from each care setting to appreciation each
others roles, challenges, and necessary skill sets.
• Case Managers have begun quick meetings twice a
week to review patients. “A take away” from the Nursing
Home Experience.
• All agree that the paperwork on discharge is
overwhelming.
• SCH Case manager have developed a sticker to identify
the difference between the hospital medications and the
doctors orders to help clarify the discharge paperwork
until we are able to have electronic discharge
instructions and Inter agencies.