LTACH liaison aids appropriate level of care

Increase patient transfers significantly

At Pennsylvania State University (Penn State) Milton S. Hershey Medical Center in Hershey, PA, a long-term acute care liaison evaluates patients with complex needs for potential placement in a long-term acute care hospital (LTACH), coordinates a comprehensive plan for transition with the treatment team, and works with the accepting facility and the patients' insurers to ensure a smooth transition.

As a result, the hospital has increased the number of patients it transfers to LTACHs each month from an average of 18 before the program was established to about 30 patients a month now.

"For long-stay patients with complex conditions, LTACHs can be a bridge between the acute care hospital and rehabilitation facilities, skilled nursing facilities, or home. It's a more appropriate level of care for patients who no longer meet inpatient criteria but can't safely be transferred to a lower level of care," says Amy Cutman, BSN, RN, manager of care coordination at Hershey Medical Center, which is a 473-bed tertiary care hospital with certified stroke and heart failure programs. As a Level 1 trauma center, the hospital often treats patients who have severe traumatic injuries or complex cardiac or neurological conditions that require lengthy hospital stays, Cutman adds.

Maryanne P. Dixon, RN, BSN, CPUR, LTACH liaison, reports that her position was created to decrease lengths of stay and improve utilization of intensive care beds. "We had so many patients who needed intensive care that they were backing up into our post-acute care unit, and being held in other areas," she says. "We needed a way to get them to a level of care where they can get the care they need on a long-term basis."

A large component of Dixon's job is to ascertain when the patient is stable enough to go to another level of care but still requires a high level/complex level of care. "Identifying the individuals to ensure that the window of opportunity is not missed is a critical aspect of what I do on a daily basis," she says.

Dixon works closely with the case manager/social worker teams assigned to the hospital's service lines to identify patients who might be good candidates for an LTACH stay. She meets with each team weekly, reviews their list of patients, and researches their care needs and insurance coverage. She also reviews the long-stay list, which includes any patient who has been in the hospital longer than 10 days, to determine if they might qualify for an LTACH stay.

"Part of the challenge is trying to identify patients who may qualify for an LTACH stay early in their stay so we can begin educating the families about LTACHs. We try to stay three or four steps ahead of the physicians so the family will have time to make a decision," she says.

When it's early in the stay, the liaison doesn't know precisely what care the patient will need and often recommends that the families and patients consider several options for post-acute care, including LTACHs and acute rehab. "We arm the families with information and empower them to make the best decision," Dixon says.

Each day, Dixon manages the care of 25-30 patients, in varying stages in the discharge process, with the case manager/social worker team. She typically transfers five to nine patients to an LTACH on a weekly basis. The hospital has hired a PRN critical care nurse to work as an adjunct to Dixon and to cover when Dixon is on vacation, which ensures that safe transitions occur and no detail is missed.

Once patients have been identified as potential transfers to LTACHs, Dixon works with the care coordination team to facilitate movement through the hospital as quickly as possible.

She educates the treating physicians about LTACHs in terms of the services they provide and their role in the healthcare continuum. Cutman says, "While RN case managers and social workers understand the value of moving patients through the system, we initially encountered a lot of resistance from physicians who were reluctant to discharge patients to an LTACH for fear they wouldn't get the care they need." Dixon can share quality data and other information to make physicians feel comfortable with an LTACH transfer.

When a patient is identified as a candidate for an LTACH stay, the case manager/social worker team on the unit has the first conversation with the family, then brings in Dixon to explain the LTACH level of care in more detail. She gives the families information about individual LTACHS and invites them to meet with the LTACH liaisons in the hospital.

Patients and families need a great deal of support during the process, and it's time consuming to ensure that all of the details of the transfer are addressed. "By managing this population, I free up the other case managers and social workers on the unit to focus their attention on their remaining patients," she says.

Dixon and the social work team created a Levels of Care information sheet that explains in lay language the various levels of care and what care is rendered at each. They have developed a list of questions that family members can ask when they visit LTACH facilities so they'll have the information they need to make an informed decision.

"We tell the family members that a transfer to an LTACH means the patient is getting better and no longer needs the kind of care they get in an acute care hospital," Dixon says. "We want to send them somewhere where they are at less risk for infection, where they can receive therapy and attention to their medical conditions. When appropriate, the stay will give families a longer time to make decisions for care for the patient in the future."