Project ECHO: Improving Care Transitions 

ECHO-CT team at BIDMCBeth Israel Deaconess Medical Center (BIDMC) developed ECHO-Care Transitions (ECHO-CT) to address gaps in care quality arising when a patient transitions from the inpatient hospital setting to skilled nursing facility (SNF). The goal is to promote safe and effective transitions for complex older patients by improving communication between the hospital and the SNF providers.

Within one week of discharge, hospital providers discuss each patient’s transitional and medical issues with providers at the SNF using video-conferencing technology. The BIDMC and the SNF teams include physicians, nurse practitioners, nurses, pharmacists, and case managers. These multi-disciplinary teams allow for a discussion of a wide range of issues that affect patients transitioning to SNF care, including: medication reconciliation, critical laboratory/imaging, discharge follow-up and case management issues. As part of the educational mission and a broader transitional care/geriatrics curriculum, internal medicine residents also intermittently lead the videoconferencing discussions. In a previous study published in the American Journal of Medicine this program reduced SNF length of stay, re-hospitalizations, and 30-day health care costs.

ECHO  Care

Building on previous research and with the support of a grant from the Agency for Healthcare Research and Quality, BIDMC launched a new research group of 17 SNF sites in April 2019. This new phase of the program includes an expansion of the ECHO-CT weekly sessions to include a hub at Beth Israel Needham. In, partnership with Hebrew SeniorLife and Brown University, BIMDC seeks to determine if ECHO-CT can improve clinical outcomes and reduce cost and resource utilization during transitions of care in both an academic (BIDMC Boston) and community (BID Needham) hospital.