Competitors Collaborate in SNF Care Coordination Network

Thursday, April 7th, 2011
This post was written by Patricia Donovan

Summa Health System’s partnership with dozens of SNFs proves competitors can partner to address a common goal — in this case, reducing adverse outcomes from poorly managed transfers and sharing accountability for the care of these patients.

Summa Health System reported that its SNF Care Coordination Network is reducing length of stay and mortality rates and improving outcomes for patients transferred between hospital and skilled nursing facilities during a “Improving Transitions of Care Between Hospital and SNF: A Collaboration Supporting the Accountable Care Vision,” sponsored by the Healthcare Intelligence Network.

The steps leading to the creation of the SNF care coordination network are a boilerplate for healthcare partnerships — from the development of the RFP and task force to the introduction of the network to the health system, according to Carolyn Holder, manager of transitional care for Summa Health System, and Michael Demagall, administrator of Bath Manor & Windsong Care Center, an SNF participating in the network. Both shared the challenges and details of the partnership and early results from this venture.

The network targets some of the key breakdowns in the transfer process, including incomplete patient assessment, lack of patient data and communication barriers between staff members, departments and sending/receiving entities. Program highlights include the introduction of a Physician Orders & Transfer Form to standardize transfers and the use of staff scripts to overcome patients’ and caregivers’ resistance to SNF care.

The goals and outcomes of the program — which include reduced admissions, readmissions and ED visits by this vulnerable population — also fit neatly within the definition of accountable care and the IHI’s Triple Aim initiative.

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