In the scramble to deal with regulations and dollars we sometimes lose sight of the individuals. Great companies always come back to improving the lives of the people they serve.
The hospital readmission problem is always framed in the context of bottom line dollars to the hospital, with post-acute care providers (skilled nursing, home health and assisted living) all jockeying for position to help hospitals reduce their 30 day readmission statistics. The end goal for the post-acute providers is to get a larger share of the hospital discharge pie.
While this paints an accurate picture, it is not the big picture. The big picture is that reducing hospital readmissions is good for people as well as the hospital.
Preventing readmissions means patients/residents (we will use the term residents going forward) are getting better faster. Too often this gets lost in the scramble for dollars. However, it is good for residents only if done right. Doing it right means comprehensive coordination between the acute hospital and various post-acute settings that might touch the lives of any given resident. This is not such an easy thing to accomplish.
Care Transition Paths
Within the context of readmission there are 5 typical paths that patients/residents follow.
- Hospital to Skilled Nursing/Assisted Living – becoming a long-term stay
- Hospital to Skilled Nursing to Home – Ideal
- Hospital to Skilled Nursing to Hospital – What everyone is trying to prevent
- Hospital to Home/Assisted Living – Ideal
- Hospital to Home/Assisted Living to Hospital – What everyone is trying to prevent
Because we are focused on senior living/skilled nursing issues, the most important paths for this article are the first three. Regardless of which path an individual follows there are some key elements that increase the likelihood of a successful, or at least optimal, outcome:
- An accurate assessment of an individual’s readiness to be transitioned from one level of care to another.
- The transfer of the right data from one care entity to another where there are two risks: If too little data goes with the individual there could be significant, even catastrophic, consequences. If too much data goes with the individual it could mask the information that is important.
- Effective coaching of the resident and family members during and after each transition.
Signature Healthcare Leading the Pack
I spent some time talking with Kara Plaks, the director of Strategic Partnerships for Signature HealthCARE a Louisville, KY-based company that operates 90 communities, mostly skilled nursing, in seven states. They are well known for innovating in the post-acute space. Signature has taken an aggressive leadership role in creating an optimal transition process that provides the best outcomes for residents and, as an additional benefit, reduces hospital readmissions. This well-developed but evolving system starts with a care transition coordinator who works for Signature but is based in the acute hospital setting. This person does an initial evaluation of each potential transfer to a Signature skilled nursing community, looking at the individual’s “transfer readiness”. That information then becomes the base for all future transitions. The key to transition success is patient education and training prior discharge by Signature. Their coaches are experts in teaching and training with a particularly focus on having patients do teachbacks that reinforce the educational sessions. One resident may review their medications and schedules while another may describe their oxygen regime. The education is then supported by a series of telephone follow-ups, the first 24-48 hours after discharge; the second 7 days after discharge; and a third 14 days after discharge.
Caremerge Manages the Process
Care coordination is a process that has a lot of moving parts. Signature started out tracking it all on paper and found steps were missed, training was missed or not as effective and communication with various stakeholders didn’t happen like it should. They teamed up with Caremerge to create a more effective system for providing the very best care transition experience for their patients. Here is what it looks like:
- The Transition Coordinator in the Hospital does the initial transition readiness evaluation and that information goes into the Caremerge system.
- As care progresses in the Signature SNF, additional care data is captured in the Caremerge system
- As transition to the next lower level of care (home or assisted living) approaches, training and coaching of the patient and family begins and the Caremerge system is used to ensure that all tasks are both completed and effective.
- Along the way stakeholders for each resident are identified and added to the patient record to ensure they will get timely, accurate information throughout the transition process.
- The system triggers follow-up calls and interventions as needed.
- Finally, over time, the system will generate data that will be used to demonstrate the effectiveness of the Signature transition process and to continue to improve the process.
Caremerge is focused on making resident data manageable and available to the right people at the right time. In the case of Signature Healthcare it makes possible something that could not be done properly in a paper system. If you are struggling with managing complex communication paths it might be worthwhile to have a conversation with Caremerge. Steve Moran
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