Program bridges acute, post-acute care
Network of providers meet with hospital reps
As part of its Total Wellness Torrance readmission reduction program, Torrance (CA) Memorial Health System has created its own network of post-acute facilities and works closely with them to coordinate care during transitions and for 30 days after discharge from the acute care hospital.
The program also includes a readmission prevention protocol in the emergency department to reevaluate readmitted patients and identify alternative levels of care to a hospital readmission, a Care Transitions program with staff who meet weekly with post-acute providers to collaborate on care for patients, and a Care Coordination Center, a post-discharge clinic where clinicians perform medication reconciliation and review the discharge instructions with the patient and family members.
"This program bridges the gap between acute care at hospitals and post-acute care at nursing facilities, working to rehabilitate patients and return as many as possible to their own homes. Nursing homes have joined together with the local hospital to improve quality of care in the community," says Josh Luke, PhD, FACHE, vice president of post-acute services at Torrance Memorial Health System and founder of the National Readmission Prevention Collaborative.
The Total Wellness Torrance Post Acute Network includes seven privately owned free-standing skilled nursing facilities, as well as a home health agency and a hospice, both of which are affiliated with the health system. All of the post-acute network members have committed to participating in quality initiatives and data-tracking efforts. Their staffs collaborate with Torrance Memorial's case management staff to ensure safe transitions and coordinate care and discharges for patients during the post-acute stay.
"We gave the providers in our area a set of quality guidelines and chose to work with the ones who have committed to our quality initiatives and are interested in coordinating care for our patients. We work with the skilled nursing facilities like an integrated network even though we are not. The network includes only facilities within five miles, which allows for improved coordination and collaboration with the skilled nursing facilities," Luke says.
Representatives from the hospital, including attending physicians, meet with skilled nursing facility representatives every other month and discuss current trends, legislative updates, how transitions are going, readmission rates, and how to improve communication and care coordination. The result has been a smoother handoff for patients and a shorter length stay on the acute care side as physicians feel more comfortable that patients are going to be well cared for at the next level of care, Luke says.
Care for the patients in the hospital may be coordinated by a trio of case managers who work together closely. The acute care case manager coordinates care during the hospital stay and works with the treatment team to develop a discharge plan. A patient navigator educates patients with post-acute needs on the health system's post-acute Care Transition program, and works with the ambulatory case manager who follows patients while they are receiving care from post-acute providers.
When the physicians write a discharge order, they have the option to check a box admitting the patient into the Care Transition program. This triggers a consultation by a patient navigator, a case manager with a close working relationship with the hospital's post-acute network, who meets with patients, describes the program and the participating providers, and gets the patient's agreement to participate. "While patients are still presented a complete list of post-acute providers from which to choose, the Care Transitions program includes only preferred providers," Luke says.
After the patient consents to the program, the navigator hands the patient back off to the acute care case manager to facilitate the transfer. Each week, the ambulatory case manager and the navigator meet with the staff at each skilled nursing facility, talk about each patient, and discuss the discharge plan and whether the patient will require home health or other services. As discharge approaches, the team makes sure the patient has a follow-up appointment at Torrance Memorial's Care Coordination Center and that the patient will have transportation to the appointment.
When Medicare patients who were discharged from the hospital come into the emergency department within a 30-day period, the hospital's electronic medical record system alerts the hospital's readmission prevention manager by email in real time. The readmission prevention manager meets with patients in the emergency department, finds out why they are back, and works with them and the emergency department staff to identify an alternative level of care that would be a more appropriate placement that an acute hospital admission. The readmission prevention manager also educates the patient on alternatives to returning to the emergency department and may schedule an appointment with the health system's Care Coordination Center.