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ECHO-Care Transitions (ECHO-CT) intends to ensure continuity of care and alleviate the risk of patient safety issues, notably medication errors, occurring because of hospital transition. With funding from the Agency for Healthcare Research and Quality, Beth Israel Deaconess Medical Center (BIDMC) adapted Project Extension for Community Healthcare Outcomes (ECHO) to connect receiving multidisciplinary skilled nursing facility (SNF) teams with a multidisciplinary team at the discharging hospital. Within one week of discharge, hospital providers discuss each patient’s transitional and medical issues with providers at the SNF using videoconferencing technology. The innovation has successfully reduced patient readmission and SNF length of stay.

Innovation Patient Safety Focus

ECHO-CT seeks to prevent patient safety events (e.g., readmission) that can result from errors during care transitions by providing clinicians with the framework for knowledge sharing and enhanced communication.

Evidence Rating

High, based on pilot results that included a comparison of data between intervention SNFs and matched control SNFs.

Resources Used and Skills Needed

BIDMC recommends interested sites confirm they have the following in place to support successful implementation:

  • Ensure that both the hospital and the participating SNFs have the technology necessary for teleconferencing, and particularly that they have the ability to connect via video. BIDMC conducted a technology run-through with the participating SNF information technology departments prior to beginning implementation and provided SNFs with webcams whenever necessary.  
  • Identify one or two individuals who can serve as the primary point (or points) of contact at each site. Responsibilities primarily include confirming which patients are to be discussed during the weekly meetings, gathering and sending patient medication lists to the hospital hub each week, and ensuring that the rest of the team joins the weekly call. The SNF and hospital are responsible for identifying these individuals, but the role is often filled by floor nurses.
  • Identify individuals to serve in key innovation clinical roles. These roles and responsibilities can be shared by multiple staff members if staff bandwidth is too limited for any one person to take on all responsibility.  

BIDMC has also developed resources for facilities to use, including case study presentations, prescribing information, an ECHO-specific process guide and intake form, and a program toolkit.

Use By Other Organizations

This innovation is not in use by other organizations. To date, 11 BIDMC Boston SNFs and 7 Beth Israel Deaconess Hospital Needham SNFs are participating.

Developing Organizations

Date First Implemented

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