When NYC Health+Hospitals’ acute care hospitals and post-acute facilities began collaborating in a pilot project, they were able to place challenging patients in the appropriate level of care — a program that is on track to save the public hospital system $3.5 million per year when it is rolled out systemwide.

  • At weekly videoconferences, staff at NYC Health+Hospitals/Bellevue discuss patients who no longer meet criteria for acute care but can’t be discharged. Staff at post-acute NYC Health+Hospitals/Coler determine if they are able to take the patient.
  • During the pilot project, staff from Bellevue visited Coler to find out what services they provide.
  • When questions about a patient arise during the videoconference, a team from Coler visits Bellevue to assess and interview the patient.

Difficult-to-place patients, some of whom have been in an acute care hospital for a year or longer, are being transitioned to a more appropriate level of care through NYC Health+Hospitals’ Better Way to Live program that promotes collaboration between acute care and post-acute facilities.

One key to the program’s success is a weekly videoconference between acute hospital staff and post-acute facilities, during which the clinicians discuss what they call “alternative level of care patients” — those who no longer meet criteria for an acute level of care, but are challenging to discharge to the next level due to medical, mental, or social issues, says Maureen McClusky, FACHE, senior vice president for post-acute care for NYC Health+Hospitals.

NYC Health+Hospitals is the largest public health system in the nation and includes 11 hospitals, trauma centers, neighborhood health centers, skilled nursing homes, home care services, and other post-acute care providers. The organization serves more than 1 million patients each year at more than 70 locations across New York City’s five boroughs.

“We started the Better Way to Live project in response to requests from many hospitals in the system who asked for assistance in transitioning patients who had been in acute care for a long time, some more than a year,” McClusky says.

A pilot project between two of the largest facilities in the system was so successful that the health system leadership is rolling it out systemwide, a move that will save an estimated $3.5 million annually.

Patients with lengthy stays may be homeless, experience drug or alcohol issues, suffer dementia, or other reasons they can’t be discharged and need round-the-clock attention, McClusky says.

The most challenging patients are clinically complex, have longstanding behavioral health issues, a history of substance abuse, and/or no social support system. They were admitted to the public hospital system because they needed medical care. They need post-acute care but because of their social and medical challenges, it is virtually impossible to place them in private post-acute facilities, McClusky says.

Many of the patients with long stays remain in the hospital for safety reasons, McClusky says. They may be violent and be a danger to themselves or others. Some patients with dementia have a tendency to wander.

“Acute care hospitals aren’t the ideal setting for these kinds of patients who need specialized units with mobility alarms, heightened security, and a wide variety of daily activities,” says Marcy Pressman, deputy executive director of NYC Health+Hospitals/Bellevue.

Bellevue plays a crucial role in the system as the transfer and referral center for the most complex patients who require a high level of medical expertise, she adds.

“In order to serve all of the patients in the system in the right setting at the right time, it’s critical to move patients who no longer need to be in Bellevue,” Pressman says.

Before the pilot program began in June 2016, acute care hospitals discharged patients to post-acute facilities within the geographic area. The organization’s leadership decided to divide all of the providers in the system into three service lines: hospitals, ambulatory care, and post-acute care, McClusky adds. Now, hospitals can transition patients to any other entity in the system.

For the pilot project, multidisciplinary teams from Bellevue and Coler held weekly videoconferences to discuss the hospital’s alternative level of care patients and whether Coler could accommodate them. Coler is an 815-bed skilled nursing and rehabilitation facility.

Staff from Bellevue visited Coler to see what services the facility could provide, and Coler formed a clinical assessment team to visit the acute care hospital and assess potential transfers. The teams from each facility included the director of social work, the unit social worker, a nurse from the unit, and the chief medical office.

“We discussed the patients’ capabilities, and opportunities for placement. There were open discussions on both sides,” says Leah Matias, RN, MS, LMHA, AMP, deputy executive director at NYC Health+Hospitals/Coler.

Patients on the list include those who must have one-on-one monitoring, those with aggressive behavior, people who require restraints, and those who have dementia as a comorbidity. Coler has a highly rated secure memory care unit and round-the-clock activities, allowing staff to discontinue or reduce the one-on-one monitoring and use of restraints, Matias adds.

The initiative has helped staff at the two facilities gain understanding and information about each other, McClusky says.

“When the Bellevue team visited our facility, they told us they didn’t realize that we could care for patients who have medical needs as well as those who need to be on a memory care unit. Through the teleconferencing and visits, they understand what we are capable of doing,” says Robert Hughes, chief executive officer of NYC Health+Hospitals/Coler.

The Clinical Assessment Team at Coler found their visits to patients in the acute care hospital helps expedite the decision to take a patient, Matias says.

“We review the records, but sometimes the records don’t say everything. We do a preliminary assessment via videoconferencing, but bringing the team in to interview the patient and staff eliminates the time lag when we need more information,” she adds.

The people on the team are the ones most likely to be caring for the patient. The team typically includes the unit nurse, a social worker, and a psychologist or psychiatrist, all of whom are assigned to the unit where the patient is likely to be placed.

Staff at both facilities in the pilot reported success. Coler has doubled the admissions they receive from Bellevue, according to Hughes.

“This program was a huge success for us. We saw a 66% reduction in the longest lengths of stay among alternate level of care patents,” Pressman adds.

“We are looking at the full range of services available in the continuum of care and which type of setting will benefit the patients most. It’s not just a better system for the organization — it’s a better path for patients,” Hughes says