Linking with an IDS? Make it easy for patients

Ensure quality of care across the continuum

A concept that sounds simple on paper can be surprisingly full of twists and turns in real life. The same can be said for life in a rehab unit after becoming part of an integrated delivery system (IDS). The advantages to becoming part of an IDS are numerous, rehabilitation managers say, but one major challenge is to make the continuum of care as smooth as possible for patients as they move through the system.

Staff education and forwarding initial patient evaluation forms are two key strategies the Dela ware County, PA-based Crozer Keystone Health System has used to ensure patient care flows smoothly, says Bonnie Breit, Crozer Keystone’s administrative director of rehab service. The Crozer Keystone system includes five hospitals, three hospital-based nursing homes, five outpatient satellite offices, and several physician practices that are part of the network.

Rotate staff to build knowledge

When a patient is moved from acute care to inpatient rehab, for example, the acute care therapist photocopies the initial patient evaluation form and sends it to the inpatient rehabilitation unit.

The therapist handling the patient in inpatient care simply adds new goals, rather than doing an entire patient evaluation from scratch and filling out the related paperwork that goes with it. Usually, the therapist discharging the patient from one continuum will call the new therapist to discuss the patient’s progress.

In addition, Crozer rotates therapists throughout the system so they can gain an appreciation for the type of care patients receive in each part of the continuum. A therapist might spend six months in inpatient rehab and then move on to outpatient care for an additional six months, for example.

Legacy HealthCare in Portland also has educated staff to ensure a smooth transfer of information, says Frank Wong, MD, medical director of rehabilitation services at Legacy. Physicians’ performance reviews include an evaluation of how quickly they complete discharge reports, he says.