When transfers to and from the hospital are necessary, OPTIMISTIC’s goal is to improve communication and safety. Many nursing facilities use electronic medical records (EMRs) that unfortunately do not interface with hospital EMR systems. In order for OPTIMISTIC to work to its maximum potential, RNs and NPs require access to their patient’s detailed clinical information from the major hospital systems in the area.

When patients return from the hospital, the on-site NP makes a transition visit to review a number of items, including detailed medication reconciliation, resident and family education, and goals of care. The RN conducts a root cause analysis immediately after the transfer to keep record of the transfer and determine any needs for improving the quality of future transitions. He or she also looks for trends that indicate a need for facility-wide quality improvement. The LTC facility is then provided with a monthly report about hospitalizations to keep the staff up-to-date on decision-making and quality improvement standards. All of this information is used to help the staff keep their patients out of the hospital and make future necessary hospital visits as uncomplicated as possible.