Critical Path Network

Easing transition from hospital to LTAC

Education of families, physicians one key to success

Faced with capacity challenges, the case management department at Harris Methodist Hospital in Ft. Worth, TX, is collaborating with representatives from local long-term acute care hospitals (LTACs) to develop ways to improve transitions of care from one facility to another.

"Our capacity is a constant challenge. In 2007, we were at 99.7% capacity. One of our goals is to get patients who no longer require acute care into the best level of care, helping us serve the most acutely ill patients. We want to make sure that the transition occurs in a timely fashion and in a safe manner and that all the stakeholders are satisfied with the transition of care," says Mari J. Finley, RN, MBA, director of medical management.

The LTAC Community Collaborative committee, which meets twice a year, includes physicians, RN case managers, and social workers from the hospital and liaisons from the long-term acute care hospitals, who represent a multitude of disciplines including RNs, social workers, and speech therapists.

"We wanted to open dialogue with representatives of the LTACs and work on ways to make discharging our patients to the LTACs as easy as possible for everyone involved. As we move forward, we plan to expand the committee to include other physicians as well as members of the community," Finley says.

The team is working to develop a best practice model for discharging and transitioning patients from acute care to post-acute care and to create outcomes metrics to measure progress in each step. The National Transitions of Care Coalition standards have been extremely helpful to the group, Finley says. (Editor's note: For information on NTOCC, see their web site at

The committee has put together a visual patient-centered model that focuses on the stages of transition and what should happen during each. The transition points include the assessment to determine LTAC appropriateness, communication to the family; physician order, LTAC referral, consulting/attending physician agreement, payer notification, family choice/agreement, transportation, and arrival at the LTAC.

Educating physicians, patients

"Our goals include moving the patients through the continuum as quickly as possible, providing tools to facilitate the discharge process and care transitions for patients and families, and educating our physicians to understand the kind of services that long-term acute care hospitals can provide and which patients are appropriate for discharge to an LTAC," Finley says.

Physicians don't completely understand the criteria for discharge to an LTAC, Finley says, adding "we are working to help the physicians feel comfortable in transitioning their patients to another level of care sooner, rather than later."

Since LTACs are relatively new to the Fort Worth area, many families do not completely understand the services they provide and the difference in LTACs and other levels of care, Finley adds.

"We are working to educate them on the advantages of LTACs and how they differ from skilled nursing facilities and the acute care hospital. LTACs provide a lot of the same treatment as an acute care hospital and they do it very well," she says.

The committee's work already is paying off, Finley says.

The collaborative work sessions have helped educate everyone on the committee about the difference in services provided by an acute care hospital and an LTAC, the special services that each LTAC in the Fort Worth area can provide, and what is involved in transferring the patients between facilities, she adds.

"By working with the LTAC representatives on the committee, our case managers and social workers better understand the special skill sets at each individual facility, which in turn, helps us determine which patients are most appropriate to transfer to which facility," Finley says.

The hospital's case managers and social workers have developed a closer relationship with the LTAC staff, facilitating the handoff of patients, she says.

"We have communication and dialogue that didn't happen before. In the past, they'd get a referral and they'd come and do their thing and we'd do our thing without much collaboration," Finley says.

Transportation issues have been identified as major barriers to a smooth and timely transition of patients between the hospital and the LTAC, Finley says.

"Many times, by the time we get the discharge order, it's late in the day and transportation to the LTAC can't be arranged until the evening. This may create problems for the LTAC," she says.

The committee has put together a spreadsheet of each transportation service in the community, including hours of operation and capabilities.

For instance, the city's ordinance requires that patients who need intensive medical oversight must be transported by a firm with an emergency medical service license.

"Transportation has been one of our barriers. This chart helps our staff choose a company that is available and is capable of transporting a particular patient. This way, we can transition patients in a timely manner as soon as the discharge orders are written, rather than having to wait until the next day," Finley says.

Harris Methodist Fort Worth has a unit-based model of case management, with case managers and social workers collaborating on each unit. The case managers have a caseload of about 30 patients and are responsible for leading the team. They oversee the clinical utilization management reviews and review the clinical criteria to help direct the social worker into the appropriate level of care following discharge.

When a physician makes an order for an LTAC assessment, the case manager and social worker communicate with the patient and family about the referral and discuss the reason for the referral in easy-to-understand language. They give the family the expected transfer date and help them understand how the process will move forward and what role they will have in the transfer.

They work with the LTAC liaisons who come to the facility to assess whether the patient is appropriate for their facilities and collaborate with them to facilitate the transfers.

If the patient is appropriate for transfer to more than one facility, the family visits the facility and chooses the one they prefer.

"We work with the physicians to communicate the family's decision and whether or not the LTAC can accept the patient. Then the physician makes the discharge decision. Our acute care physicians may not practice in the LTAC setting so they have to have a comfort level with transferring their patients," Finley explains.

When the physician order is written, the case managers contact the insurance company for approval. They work with the social workers to help find funding for the unfunded patients. For instance, some LTACs don't accept Texas Medicaid.

When the patient is ready for discharge, the case managers arrange for transportation, based on patient needs, and fill out the paperwork for transfer.

The hospital is getting an electronic referral system that is expected to reduce the turnaround time from the time the patient is referred to the time the LTACs accept the transfer.

"We are working to improve the time it takes to get the patient transferred from the hospital to the LTAC once the discharge is planned. It's a slow process, but we're making progress," Finley says.

(For more information, contact Mari J. Finley, RN, MBA, director of medical management, Harris Methodist Hospital, e-mail: