October 2012

LINCT program aims to reduce unnecessary hospital readmissions from area SNFs

Northwest Community Hospital (NCH) is making strides to curb hospital readmission rates among its most vulnerable patients by extending a caring touch that goes beyond the point-of-discharge. After nearly one year of a pilot test phase, the Hospital's LINCT (Liaison In Nursing Care Transitions) program has added a full-time staff nurse who will follow high risk patients to two skilled nursing facilities (SNF) in the area. This dedicated nurse will ensure post-discharge care plans are followed, recovery milestones are met and quality outcomes are achieved within the SNF setting.

LINCT: by the numbers

From December 2011 through June 2012, hospital readmissions stemming from a participating SNF location have decreased nearly 11 percent.

At its core, the LINCT Program is a transition of care initiative set out to achieve three objectives: to reduce 30-day readmissions, to decrease length of stay and to improve patient and family satisfaction. While hospitals – including NCH – have traditionally followed up with patients via phone and mail after discharge, the LINCT program is taking post-discharge patient engagement to a new level, explains Dina Lipowich, director of Medical Nursing and Inpatient Geriatrics at NCH.

"At NCH, we are going above and beyond to ensure a patient's care plan will continue in the new setting, specifically at skilled nursing facilities," Lipowich says. "We are putting in place the resources necessary that will ensure nursing and medical care recommendations made in the Hospital are carried through in the patient's new environment, lending to a successful and expedient transition across the healthcare continuum."

As Hospital inpatients prepare for discharge, those who will step down to a skilled nursing facility will be considered for the LINCT program. Specifically, the LINCT nurse will identify and consult with at-risk patients and their families. Patients benefiting from the LINCT program include those older in age, with chronic medical conditions and recent history of hospital admissions.

"Many patients and their families are hesitant to transition to a skilled nursing facility after hospitalization for a variety of reasons," says Lipowich, adding that this program is an opportunity to enhance the patient/family experience and satisfaction. "With the LINCT nurse at their side, patients and families are comforted knowing a hospital clinician will follow them throughout the entire continuum of care. There's relief knowing they are going to see a familiar face at the skilled nursing facility."

The LINCT nurse will follow patients for 30 days following hospital discharge, which is typically the course of their stay in the SNF setting. The LINCT nurse will round on patients with SNF care teams to ensure all aspects of both the physician and Hospital care plans are followed through. As patients transition to home, the LINCT nurse also works in concert with the NCH Home Care team for added continuity of care.

Lipowich adds that the LINCT program is the product of a deep and collaborative relationship between the Hospital and participating SNFs. Medical directors and clinical care teams from these facilities, as well as LINCT program members and Home Care representatives from NCH meet regularly to discuss patient outcomes, to share trends and insights and to evaluate variables contributing to successful transitions.

"The multidisciplinary healthcare team approach is key to our success," Lipowich says. "Together, we look at the individual patient as well as the bigger picture to identify the factors that may contribute to readmissions. The team continually implements and refines care processes that can help reduce otherwise avoidable readmissions moving forward."

To learn more about the LINCT program at NCH, call Dina Lipowich at 847.618.6510.