Virginia Community Partners Band Together to Ensure Safer Transitions and Better Patient Care

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Mark Morriss is the Administrator of Trinity Mission Health & Rehab of Charlottesville, Virginia. When Morriss first began participating in the Central Virginia Transitions Collaborative (CVTC) – established in 2014 by two area hospitals, an Area Agency on Aging and VHQC, the Quality Innovation Network-Quality Improvement Organization (QIN-QIO) for Maryland and Virginia – his main goal was to meet and connect with patient referral sources. As time progressed, however, his perspective on the group changed.

The more I attended the meetings, the more I realized the value I could glean from working with a robust collaborative of health care professionals in my community,” Morriss said.

After having open discussions on how to provide better health care services and safer transitions to local patients, Morriss realized that his health care peers and partners were all facing similar challenges. That’s when it clicked. Together, we can break down walls and achieve common goals for the benefit of patients,” Morriss said.

The CVTC meets monthly at a central location in the Charlottesville area. Members of the collaborative include local representatives from hospitals, rehabilitation hospitals, home health agencies, hospices, senior care agencies, skilled rehabilitation facilities, assisted living centers and pharmacies.

"Together, we can break down walls and achieve common goals for the benefit of patients."

Morriss said that a main focus of the group has been to improve communication between facilities in order to achieve a smooth transition of information. The group determined that the Situation-Background-Assessment-Recommendation (SBAR) technique, which has become the industry best practice for standardized communication in health care, would serve as the framework for communication in an environment where different information technology systems can complicate outcomes.

We are all responsible for providing the best care possible,” Morriss said. My end goal is to have other administrators in the area using a certain informational tool to provide the hospitals and emergency care providers with consistent patient information.”

Another goal of the CVTC is educating the patient and his or her family. The more we can educate the community, the more we can focus on providing care,” Morriss said.

The group aims to increase public understanding that local hospitals are not the only place to receive quality care. This has involved educating patients and families on what rehabilitation facilities, hospices and other health care facilities can provide in terms of care. This helps the community at large provide better care with less costly care transitions in the long run.

Patients are often afraid of the unknown. We want to provide detailed information and let them know that our goal is to get them home as soon as possible, no matter where they receive care,” he said.

Morriss also mentioned the group’s involvement in the Program of All-inclusive Care for the Elderly (PACE). PACE organizations provide care and services in the home, the community and the PACE center, so that patients can receive the best care at any particular level, according to Morriss.

Another significant component of CVTC’s meetings involves sharing best practices. We have a spotlight at our meetings where we each talk about patient stories, lessons learned and continued successes,” Morriss said. In the beginning, it was hard for us to look outside of our immediate industry and realize that we’re just a piece of the continuum. Now we see this as a clear partnership between skilled nursing, home health care, hospice and hospitals.”

In the end, we are all partners in the care of our shared residents and patients. With this type of collaboration, there is a huge benefit that participants take away. It’s up to us to do something with the information to benefit the local communities we serve,” he concluded.