Posts Tagged ‘skilled nursing facility’

Care Transitions Playbook Sets Transfer Rules for Post-Acute Network Members

July 28th, 2016 by Patricia Donovan

St. Vincent's Health Partners best practices care transitions playbook documents more than 140 patient transfer protocols.

St. Vincent’s Health Partners best practices care transitions playbook documents more than 140 patient transfer protocols.

A primary tool for Saint Vincent’s Health Partners Post-Acute Network is a playbook documenting more than 140 transitions for patients traveling from one care setting to another, including the elements of each transition and ways network members should hold each other accountable during the move. Here, Colleen Swedberg, MSN, RN, CNL, director of care coordination and integration for St. Vincent’s Health Partners, explains the playbook’s data collection process and information storage and describes a typical care transition entry.

The playbook is made up of several sections, including one with current expectations, based on the Michigan Quality Improvement Consortium, which we can review online. From an evidence-based point of view, they’ve listed the evidence for many common conditions patients are seen for in medical management. This is kept up to date. This is an electronic document stored on our Web site that can only be accessed by individuals subscribed to the network. We’ve also put this on flash drives for various partners.

A second section contains actual metrics for any network contracts. The metrics appear in such a way that the highest standard is included. For example, physician providers, as long as they provide the highest level of care in the metric, can be sure they’re meeting all the metrics. Those metrics are based on HEDIS® standards.

The third section is the transition section, laid out in two to three pages. For example, a patient moves from the hospital inpatient setting to a skilled nursing facility, such as Jewish Senior Services. For that transition, the playbook documents all the necessary tools for that patient: a personal health record, a medication list, whatever is needed. Also included is any communication with the primary care physician, if that provider has been identified. Finally, this section identifies the responsibility of the sending setting—in this case, the hospital inpatient staff. What do they need to organize and make sure they’ve done before the patient leaves and starts that transition, and what is the responsibility of the receiving organization?

That framework is the same for every transition: the content and tools change according to the particular transition. A final section of the playbook details all of the tools used for care transitions. For example, in our network, we’re just now working on the use of reviews for acute care transfers, which is an INTERACT (Interventions to Reduce Acute Care Transfers) tool. In fact, many settings, including all of our SNFs, as it turns out historically, have used that tool. This tool is in the playbook, along with the reference and expectation of when that tool would be used.

Source: Post-Acute Care Trends: Cross-Setting Collaborations to Align Clinical Standards and Provider Demands

http://hin.3dcartstores.com/Post-Acute-Care-Trends-Cross-Setting-Collaborations-to-Align-Clinical-Standards-and-Provider-Demands_p_5149.html

Post-Acute Care Trends: Cross-Setting Collaborations to Align Clinical Standards and Provider Demands examines a collaboration between the first URAC-accredited clinically integrated network in the country and one of its partnering PAC providers to map out and enhance a patient’s journey through the network continuum—drilling down to improve the quality of the transition from acute to post-acute care.

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Posted in Care Coordination, Care Transitions, Electronic Health Records, Electronic Medical Record, Hospital Readmissions, Long Term Care, Quality Improvement, Reducing Readmissions, Transitions in Care | Comments Off on Care Transitions Playbook Sets Transfer Rules for Post-Acute Network Members

Bundled Payments Opportunity to Practice Proactive Population Management

September 16th, 2014 by Patricia Donovan

Assuming financial risk for the cost of post-acute services not only helps healthcare organizations avoid value-based readmissions penalties but also provides a chance to proactively manage a population, notes Kelsey P. Mellard, vice president of partnership marketing and policy with naviHealth.

We have been called almost a concierge-type service in the way we think about management and engagement with the patient, their family, and their caregivers. We proactively provide a road map to our beneficiaries based on their functional score. Our tools and technology identify their functional abilities upon discharge from the hospital and use that as a driver for identification of a post-acute care setting.

Our functional score is comprised of three domains: basic mobility, applied cognition and daily living skills. Through the assessment of the patient, we identify a patient in our database just like the patient in front of us and say, ‘Patients just like this patient have gone to skilled nursing facilities (SNFs) or home health and have had this level of functional improvement over the course of this length of stay, this many therapy hours per day, and this patient presents with X% of a risk for readmission. Through that prediction, based on historical real patients in our database, we can identify and help target the level of acuity and care this patient actually needs in a post-acute care setting.

Often we discharge patients to a higher level of acuity and care than they actually need. This gives us a tool. It’s not a rule. It’s not the be-all, end-all in our hospital partner settings, but it does create another piece of information based on real patients to help inform the discharge planning process.

We see the level of excitement and engagement our hospital partners exhibit on the ground floor, because right now they’re discharging based on community knowledge or because a case manager really likes one facility or they’re financially interested, from an organizational standpoint, in one facility. This negates all of those conversations and says this is an evidence-based model we’re going to be able to deliver at the bedside.

Source: Bundled Payments: Opportunities in Effective Retrospective Acute and Post Acute Care Bundles

Bundled Payments


Bundled Payments: Opportunities in Effective Retrospective Acute and Post Acute Care Bundles First quarter experiences from these pilot programs, along with the current bundled payment opportunities for organizations not yet participating in CMMI’s pilot program.

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Physician Group ACOs Value Specialists, Nurse Practitioners

March 19th, 2014 by Jessica Fornarotto

As the number of public and private accountable care organizations nears 500, participants are fine-tuning the ACO model. In the few years since the ACO model entered healthcare’s consciousness, administration has shifted from hospital-led to physician-only leadership to PHO-helmed ACOs. In its third annual industry survey on ACOs, conducted in 2013, the Healthcare Intelligence Network captured how 138 healthcare organizations are participating in ACOs.

Drilling down to the multi-specialty physician group perspective, this survey analyzed the number of existing ACOs for this sector, which providers participate in the ACO, and more.

With their built-in cadre of healthcare providers, multi-specialty physician groups (referred to here as physician groups), which comprised about a tenth of survey respondents, would seem ideally placed to transition to accountable care organizations. Percentage-wise, this sector has the highest rate of existing ACOs (57 percent participating in ACOs versus 34 percent of overall respondents) and twice the rate of participants in the CMS Pioneer ACO program (25 percent versus 13 percent).

In other deviations from the norm, twice the number of physician group-reported ACOs favor the hybrid FFS + care coordination + shared savings payment model (75 percent of physician-group ACOs versus 37 percent of overall respondents).

More than half of ACOs in this sector are administered by independent physician associations (IPAs), and most are smaller than the hospital-sized ACOs reported in the survey, with three-quarters reporting a physician staff of less than 100. These ACOs benefit from having specialists on board in greater numbers to help with care coordination of the chronically ill (100 percent include specialists, versus 71 percent overall).

They also unanimously include nurse practitioners (versus 90 percent of overall respondents) and with 50 percent including clinical psychologists in the ACO (versus 42 percent overall), are a little further along on the path of integrating behavioral health into the accountable care initiative.

Cognizant of the full care continuum, these IPA-led ACOs are almost twice as likely as overall respondents to include skilled nursing facilities (50 percent versus 29 percent overall) and hospice (75 percent versus 42 percent overall) in their ACOs.

Excerpted from: 2013 Healthcare Benchmarks: Accountable Care Organizations

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Award-Winning Protocol Puts Readmission Prevention Manager in ER to Reduce Rehospitalization Rates

February 13th, 2014 by Cheryl Miller


Call it a bouncer of sorts for the emergency room: the readmissions prevention manager, or RPM for short, has helped Torrance Memorial Health System reduce all cause readmissions by nearly 5 percent, and earn its hospital system kudos from the industry, says Josh Luke, Ph.D., FACHE, 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.

Designed to determine whether newly admitted high-risk patients are ready for the emergency room (ER), or could be placed elsewhere, the RPM is an integral part of a strategy implemented in 2013 for Total Wellness Torrance (TWT) to reduce preventable readmissions, Luke said during Award Winning Readmission Prevention Protocols: Navigating Care Transitions with Preferred SNF and Home Health Providers , a 45-minute webinar on January 8th, 2014, now available for replay.

He shared the key features of this program, which was recognized by California Association of Healthcare Facilities as a Program of Excellence in 2013. At the time, the 401-bed not-for-profit hospital was achieving readmissions rates that were in step with national averages, generally within 18 to 20 percent, and some quarters exceeding that. Torrance felt it could do better, approaching the problem from an all-cause, rather than disease-specific perspective, Luke says.

Creating the RPM was the first step in the process, he says. This person would function as the leader of the hospital readmission prevention team, making sure only patients who meet criteria and need to be hospitalized are admitted either to the observation floor or to the inpatient unit.

As Luke explains: the RPM gets a real-time email alert any time a patient comes to the ER and their social security number is entered into the hospital’s electronic system. Their number one priority is then to go right to the ED to meet the patient and work with the attending doctor, case manager and nursing team in the ER to see if this patient can be cared for at a lower level of care.

That’s essentially what the Affordable Care Act has encouraged us to do and incentivized us to do and penalized us when we don’t do that efficiently, which is not to admit patients to the hospital that don’t need to be here. We are very encouraged by the success of that program in its initial six months.

The RPM then follows those patients who were not admitted to the ED to a post-acute network facility, at all times keeping in mind patient choice. TWT includes a post-acute network of eight skilled nursing facilities (SNFs), all within five miles of the hospital, and a home health agency. Along with a home health department navigator, the RPM goes to each SNF once a week to follow up on patients, determining discharge plans and employing an ambulatory case manager if the patient goes to a home health agency outside the Torrance network, and keeps tabs on them long after the 30-day readmission period is over.

Collaboration and communication with the post-acute network (PAN) is key to success, Luke says. “Whenever I’m asked if I could name three basic things to prevent readmissions, the first thing I always refer to is telling your skilled nursing facilities to invest in predictive software because it doesn’t cost you as a hospital anything. It enables you to share data with the SNFs.”

That, and always be a champion of choice for your patients, Luke adds, even when they’re being bounced out of the ER.

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Posted in Avoidable ER Use, Care Management, Care Transitions, Case Management, Electronic Medical Record, Hospital Readmissions | Comments Off on Award-Winning Protocol Puts Readmission Prevention Manager in ER to Reduce Rehospitalization Rates

Transfer Form Standardizes Communication During Care Transitions

February 11th, 2014 by Patricia Donovan

Clear patient transfer instructions reduce the risk of readmission.

To improve communication and the quality of information accompanying patients during transfer from hospital to nursing home, Summa Health Systems worked with its preferred skilled nursing facilities (SNFs) to develop physician orders and transfer care forms. Mike Demagall, LNHA, LPN, administrator with Bath Manor and Windsong Care Center, two participating SNFs, describes the development process.

This is the first project that we worked on where we identified with surveys that communication was the number one issue. In addition to a nursing facility process and referral, the physicians’ orders and transfer care form was developed by care coordination.

It took some time to develop this program and form. We were able to reduce the amount of information being sent to the nursing home and provide information that was required for the doctors at the nursing home, which is their system of payment. It provides clear and concise physician orders. It provides extra blank areas for consultants and additional information that may go on there. There is nursing documentation of the plan of care and other nursing information on the other side. The front side is for the physician, and the back side has nursing information and a list of the chart forms that must accompany the patient.

This form took about a year to develop, and we have suggestions on how we may want to adjust the form once or twice a year. In addition to our small care coordination network, this went out to the Akron Regional Hospital Association. As the area SNFs and the Summa Hospital collaborated, that was where they met. The form helped standardize the communication. Additionally, we had the buy-in from the Akron Regional Hospital Association, which several of our members from the care coordination are a part of, as well as Summa Hospital.

They were able to implement that form in the community as a whole, not just between form and the care coordination network.

Excerpted from: Accountable Care Strategies to Improve Hospital-SNF Care Transitions

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4 Trends for Healthcare Providers in 2014

January 30th, 2014 by Jessica Fornarotto

Dual-track medical homes, e-visits, retooled patient handoffs and more post-acute care are predicted provider trends for 2014, according to Steven Valentine, president of The Camden Group. HIN interviewed Valentine prior to his presentation during an October webinar on Healthcare Trends & Forecasts in 2014: A Strategic Planning Session.

HIN: What is the physician practice going to look like in 2014? How has the primary care team evolved to meet the Triple Aim values inherent in the PCMH and accountable care models?

(Steven Valentine): We should expect to continue to see consolidation amongst the medical groups. The independent practice associations will begin to assimilate together because they need to put more money into their infrastructure. And many of the organizations have underperformed, in all honesty.

The primary care team is still critical. We’ve benefitted by keeping many primary care doctors around because they were negatively hurt with their net worth in the recession in 2008-2010. But it’s slowly coming back and we’re starting to see those physicians thinking about retirement again. The reality is, we’re never going to replace all of these primary care doctors as they wind down their practice. We need to do a better job of getting telehealth going and utilizing e-visits. We’re seeing the health plans starting to pay for those e-visits, as well as having the consumer who uses them use a credit card and pay at that time, just like a visit.

We’re going to have to look at different models. Obviously, the nurse practitioner is getting more involved with the primary care. And yes, they’re still pursuing the Triple Aim. We know that quality scores, satisfaction scores and trying to manage cost per unit is still a critical focus of the triple aim moving forward with population health.

Lastly, with a PCMH in accountable care, while some of the pioneer accountable care organizations (ACOs) reduce themselves out of pioneer into the Medicare Shared Savings Program (MSSP), we still have a number of organizations and it’s growing. The commercial ACOs have been very successful in California.

We fully expect accountable care to continue. We think the PCMH will evolve into two tracks. The first track is a primary care PCMH. The spinoff is a chronic care medical home that has the multidisciplinary team organized around a chronic disease. This is a model developed by CareMore years ago in Southern California and it’s been expanded across the country. As I travel the country, I run into organizations that have set up these chronic care centers around the chronic disease.

HIN: Regarding the Pioneer ACO program, one of the top performers in the CMS pioneer program, Monarch HealthCare, told us that it’s going to be working to engage specialists in care coordination roles in year two and year three. What’s ahead for specialists in terms of quality and performance improvement as well as shouldering perhaps more care coordination duties, especially for Medicare patients?

(Steven Valentine): The specialists are going to be a critical piece to this whole solution. They have been a tremendous asset in the area of bundled payments, where you have the facility fee and physician fee combined into one payment. That works for both the Medicare as well as the commercial side. You’re beginning to see more of the bundled payments within an ACO.

The ACO manages what we call ‘frequency’ — in other words, the number of procedures to be done. Specialists are involved in satisfaction, quality scores, and resource consumption once the decision is made that the procedure needs to be done.

We expect the specialists to be involved with quality and performance. Everybody is putting in incentive programs to help drive higher quality, better performance, and a lower cost.

HIN: Hospitals have tightened the patient discharge process as a means of shoring up care transitions. But what other work needs to be done in terms of collaborations, perhaps with skilled nursing facilities (SNFs), long-term care and home health, for example, to improve patient handoffs and reduce hospital readmissions?

(Steven Valentine): Handoffs have probably been one of the areas where we’ve seen the most disappointment or underperformance within many ACOs. They have not effectively involved the hospitalists and the care/case managers who are typically embedded within the medical group that would oversee the patient throughout the care continuum. Or if it’s a health system, emanate centralized care/case management function where they manage all of the transitions from pre-acute, acute to post-acute. We think this will get better. As the doctors are more at risk, they will get more engaged with the care/case managers to manage these transitions and handoffs.

We also know that, while not in 2014 but the trend will start, we’ll see lower acute care utilization, pushing more patients to post-acute care. This means, in any given area, acute care hospitals will begin to convert excess capacity to post-acute care services like skilled nursing, long-term care, palliative care, hospice care, home care and rehab care. You will begin to see a closer proximity. The care managers will be able to work more effectively with the doctors and hospitals to manage the patient through the continuum, smooth out these transitions and have a better patient experience with better satisfaction scores at a lower cost.

Excerpted from: Healthcare Trends & Forecasts in 2014: Performance Expectations for the Healthcare Industry

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Posted in Accountable Care Organizations, Care Coordination, Care Transitions, Case Management, Healthcare Trends, Hospital Readmissions, Medicare, Patient-Centered Medical Home, Post-Acute Care | Comments Off on 4 Trends for Healthcare Providers in 2014

SNF Community Partnership Shores Up Accountable Care

October 1st, 2013 by Jessica Fornarotto

To support ACO construction, industry thought leaders advise hospitals to monitor what goes on across its care continuum and to partner with facilities it discharges its patients to most often to reduce 30-day readmissions. A prime example is the skilled nursing facility (SNF) network coordinated by Summa Health System, discussed here by Carolyn Holder, manager of transitional care for Summa Health System, and Michael Demagall, administrator of Bath Manor & Windsong Care Center.

(Carolyn Holder) We have been working on a pilot model for accountable care. Accountable care is the focus on primary care wellness in population health. Patients and families need to be actively engaged in this process. It coincides with having the right level of care provided to the patient where they need it, and that is what we are talking about with accountable care. You need partnering relationships between hospitals and physicians and through all levels of care to be able to support that individual in their wellness or illness effectively.

What is the value of this care coordination that worked in the accountable care model of care? It relates to the Triple Aims and looking at providing safe, patient-centered, timely care. We are collaborating to do that with our partner facilities. We have been working at improving health and patient populations in communities. Patients in this situation need rehab, so they have had some functional impairments and frailty. We are trying to get them back to their optimal level of function. To do this, we partner with our SNFs to support that level of care and lower the per capita cost of healthcare.

We also work with community-based long-term care. That has certainly not taken away from any of our nursing facilities any patients that are appropriate or keeping them in the optimal function that they would want.

(Mike Demagall) Through this development of the ACO on the skilled nursing side in working with the hospitals, one thing we focused on was the key indicator comparisons for our 2010 data.

Along with the hospital, we will provide standardized numbers of information that we can get back, that we are going to be held accountable for from the SNF side. The hospital knows what we do is safe and efficient, patient-centered and equitable for everybody involved. As we move forward with the ACO through care coordination, we will look at numbers and information that we can share as a community with the health system so they know what the facilities are doing. There are many reasons that is done, but one of the greatest accomplishments is everybody working together.

Out of 39 homes in the county, the collaboration has been incredible. Initially there was some hesitation, but the collaboration has moved forward, and we are not afraid to share that information. The information is blocked and as we provide information back, it will be blocked from other members except for the hospital, who knows who those numbers are. However, from my facility, I may see a readmission rate at one facility lower than ours although we have the same type of case mix index. I need to look at our facility and ask, “What can we do to get better? What are they doing that we aren’t?” Therefore, everybody gets better as a group, and that is ultimately the goal of the community and the health population in the community we serve.

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Posted in Accountable Care Organizations, Care Coordination, Hospital Readmissions, Hospitals, Long Term Care, Patient-Centered Medical Home, Physician Practices, Population Health Management, Reducing Readmissions, Wellness/Prevention | Comments Off on SNF Community Partnership Shores Up Accountable Care

HINfographic: How an Integrated SNF Network Supports Accountable Care

September 23rd, 2013 by Jackie Lyons

In the future, SNF readmission rates could be subject to penalties similar to those CMS has put in place for hospitals, such as when SNF readmissions to a hospital occur for certain conditions, within a particular timeframe. To avoid this, many hospitals and health systems are collaborating with SNF providers to improve care and reduce unplanned 30-day readmissions.

Reducing fragmentation and redundancy of care and reclaiming revenue from diverted admissions are just two reasons to integrate SNF networks into a post-acute strategy, according to a new HINfographic from the Healthcare Intelligence Network. This infographic not only identifies additional reasons to integrate SNF networks, but also breaks down SNFs by the numbers and offers tips for network formation.


How an Integrated SNF Network Supports Accountable Care

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Information presented in this infographic was excerpted from: Accountable Care Strategies to Improve Hospital-SNF Care Transitions. If you would like to learn more about accountable care strategies for care transitions, this resource includes a detailed case study from Summa Health System, and industry thought leaders advise hospitals to monitor what goes on across its care continuum and to partner with facilities it discharges to most often to reduce 30-day readmissions.

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