ECHO-Care Transitions (ECHO-CT) ensures continuity of care and alleviates the risk for patients, such as readmissions that can result from errors such as medication errors during care transitions.
Beth Israel Deaconess Medical Center (BIDMC) https://www.bidmc.org with funding from AHRQ https://www.ahrq.gov, has adapted the project Extensions of Community Healthcare Outcomes (ECHO) to connect receiving multidisciplinary Skilled Nursing Facility (SNF) teams with a multidisciplinary team at the discharging hospital.
One week after discharge, hospital providers discuss each patient’s transitional and medical issues with providers at the SNF. BIDMC recommends the following to support successful implementation:
- The hospital and the participating SNF needs to have the technology for teleconferencing along with the ability to connect via video
- Conduct a technology run-through with the participating SNF information technology departments prior to beginning implementation
- Identify one or two individuals who can serve as the primary point of contact at each site. Responsibilities can include confirming which patients are to be discussed during the weekly meetings
- Gather and send patient medication lists to the hospital hub each week and ensure that the team joins the weekly call
- Identify individuals to serve in key innovation clinical roles. These roles and responsibilities can be shared by multiple staff members if the staff’s bandwidth is too limited for any one person to take on all the responsibility
BIDMC has developed resources for facilities to use, including case study presentations, prescribing information, an ECHO-specific process guide, plus an intake form along with a program toolkit.
The BIDMC ECHO-CT program staff recognize that resources are likely more limited for community hospitals. While there may be a dedicated staff member for each of the multidisciplinary roles on the team at academic medical centers, these roles may be shared by multiple individuals at community hospitals.
Go to https://psnet.ahrq.gov/innovation/echo-care-transitions-sucessfully-reduces-patient-readmissions-skilled-nursing for the report titled ECHO-Care Transitions Successfully Reduces Patient Readmissions from Skilled Nursing Facilities, Reduces Length of Stay published August 25, 2021.