To hold the line on hospital readmissions, a tri-county, skilled nursing facility (SNF) collaborative in Michigan evaluates 130 participating SNFs by a host of quality metrics the SNFs enter into a common data portal.
In this podcast, Susan Craft of the Henry Ford Health System (HFHS), one of four collaborative founders, outlines a few SNF participation and reporting mandates that run the gamut from meeting attendance to LACE readmission risk scores.
During Reducing SNF Readmissions: Quality Reporting Metrics Drive Improvement, a May 2017 webinar now available for replay, Ms. Craft, director, care coordination, family caregiver program, HFHS Office of Clinical Quality & Safety, shared the key details behind this SNF collaborative, the program’s impact on readmission rates, and new readmission reduction targets derived from the program’s data analysis.
As groundwork for participation in CMS’s Bundled Payments for Care Improvement initiative, St. Vincent’s Health Partners (SVHP) formed a cross-functional cross-boundary Transitions Leadership Group to map what happens to patients moving along their care journeys, explains Colleen Swedberg, MSN, RN, CNL, director for care coordination and integration.
In this audio interview, Ms. Swedberg describes the structure and goals of the Transitions Leadership Group and some tools and protocols it developed to set standards for any post-acute provider wishing to join the SVHP network.
During a September 2015 webinar, Post-Acute Care Trends: Aligning Clinical Standards and Provider Demands in the Changing Landscape, now available for replay, Ms. Swedberg and Julia Portale, vice president of community services, Jewish Senior Services, share their organizations’ collaborative approaches to the evolving post-acute care market.
Beyond reducing per-episode costs and readmissions, Brooks Rehabilitation’s experience in CMS’s Bundled Payments for Care Improvement (BPCI) initiative helped the post-acute care provider to identify gaps in care and staff training, notes Debbie Reber, vice president of clinical services for Brooks Rehabilitation.
In this audio interview, Ms. Reber identifies how Brooks Complete Care program achieved its biggest savings as well as the care and training enhancements resulting from the rehabilitation system’s participation in BPCI’s Model 3.
During a July 2015 webinar, Bundled Payments for Post-Acute Care: Four Critical Paths To Success, now available for replay, Debbie Reber shares the inside details on the four domains of Complete Care and the resulting, significant savings Brooks achieved through the BPCI program.
With hospital readmission rates under close scrutiny by CMS, Torrance Memorial Health System launched a readmission program in early 2013 that has been recognized as a program of excellence for its innovation and impact on the community. Navigators work with patients prior to discharge from the hospital to educate them on the hospital’s Care Transitions program, which includes a network of Skilled Nursing Facilities, or SNF’s and one home health agency. And once the patient is discharged, ambulatory case managers keep watch on the patients after the 30-day penalty phase is over.
Josh Luke, Ph.D., vice president of post acute services at Torrance Memorial Health System and founder of the California Readmission Prevention Collaborative and the National Readmission Prevention Collaborative, shared the key features of the program during Award Winning Readmission Prevention Protocols: Navigating Care Transitions with Preferred SNF and Home Health Providers, a 45-minute webinar on January 8th, 2014, at 1:30 pm Eastern.
Working with a network of 40 skilled nursing facilities to hone the hospital-to-SNF transfer of care has accomplished two goals for Summa Health System: readmissions and lengths of stay for patients released to SNFs have been reduced, and the experience has made hospitals and SNFs more accountable for both the quality and cost of care they provide. Carolyn Holder, manager of transitional care for Summa Health System, describes what had to happen before this critical care transition could improve and why physicians had to rethink their approach to hospital-to-SNF transfers.
Holder and Michael Demagall, administrator of Bath Manor and Windsong Care Center, an SNF participating in the network, described their collaboration during Improving Transitions of Care Between Hospital and SNF: A Collaboration Supporting the Accountable Care Vision, a 60-minute webinar on April 6, 2011.