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Hospitals have been winking at skilled-nursing facilities and other post-acute care providers for a couple of years, but now they want to hold hands. Tightly.

Their newfound interest reflects the growing realization that post-acute providers are key to helping hospitals reduce unnecessary hospitalizations. One trigger is the financial penalties, which started in October, for hospitals that have high 30-day readmission rates. The Medicare program already is docking reimbursement to more than 2,000 hospitals, and the penalties will grow in the years ahead.

"It wasn't really until we got closer to the penalty period that the discussions began to heat up, and more substantive conversations and actions have taken place since then," says Paul Bach, an executive at Genesis HealthCare, which operates more than 200 skilled-nursing facilities and other post-acute services. "Hospitals are really beginning to recognize the value that skilled-nursing facilities can provide in helping them achieve their goals in this area."

Beyond the readmission rate penalties, hospitals have a bigger reason for casting their gaze on nursing facilities. The days when financial success was tied to a hospital's inpatient census are coming to a rapid close. Private and public payers are committed to value-based health care, which means patients must be treated in the least-expensive appropriate setting. Improving value with global payments and bundled payments will incentivize health care organizations to keep patients out of inpatient beds whenever possible.

That new perspective is prompting hospital leaders to seek innovative ways to work with skilled-nursing facilities, rehabilitation facilities and other post-acute care providers.

"As an industry, we historically have put hard stops on our services when the payment ends," says Suzanne Schut, director of older adult services at Henry Ford Macomb Hospital in Clinton Township, Mich. "We need to think more globally now and reach out to different partners."

Like any new marriage, developing a partnership with an SNF can be tricky. While both share the goal of avoiding unnecessary inpatient stays, a hospital's facilities, protocols and standards are very different from those of an SNF. And the communication gap between hospitals and nursing facilities often is larger than anyone ever realized, says Grace Jenq, M.D., medical director for inpatient medicine at Yale-New Haven (Conn.) Hospital.

"I really feel that if the hospital tries to fix the readmission problem on their own, they will fail," she says. "It will only be when they start to go outside their four walls and start talking to skilled-nursing facilities — really stepping into their shoes to understand what the issues are — that you start to uncover these barriers."

Picking Favorites

Many health systems are creating a network of SNFs that agree to meet quality standards, share data, provide certain services and work with hospitals to reduce avoidable hospitalizations. Kathleen Griffin, national director of post-acute and senior services for Health Dimensions Group, says this approach requires a thorough evaluation of the SNFs available to patients upon discharge to create a network that has adequate capacity, high quality, geographic coverage, special services and the willingness to accept hard-to-place patients.

"We are developing a partnership with skilled-nursing facilities that supports our clinically integrated health system and delivery of care," she says.

Of course, patients can choose any nursing facility they want, regardless of whether it is on a hospital's preferred provider team. But hospitals can help patients make good choices when they have data to back up their recommendations.

"Now we can actually say, 'These are the ones that we work with and are trying to reduce readmissions, and we have a relationship with them,'" Jenq says. "That never happened before."

Improving Transitions

Jenq is program director for the Greater New Haven Coalition for Safe Transitions and Readmission Reductions, or GNH CoSTARR. Through that program, two campuses of Yale-New Haven Hospital are working to reduce high readmission rates.

They use a two-pronged attack. In the first step, transition consultants — Agency on Aging-employed social workers based at each hospital — meet with patients a few days before discharge to help plan a successful transition to short-term rehabilitation or long-term care. Step 2: Registered nurses at the hospital make a "warm hand-off" to the SNF nurses 24 to 48 hours after the patient's discharge.

"Our care coordinators on the hospital side talk to the RNs on the skilled-nursing facility side to discuss the care plan and make sure that any changes in treatment are known between the two sides," Jenq says. "We feel that is very, very important — especially to go over any type of medication changes — because often that is where mistakes are made."
As the time gets closer to discharge from the SNF, the social workers contact the patients and families again and coordinate with the SNF's discharge planners to transition patients home successfully.

Representatives from a few dozen SNFs have attended meetings about the GNH CoSTARR program, and Jenq and her colleagues are visiting the 15 high-readmission facilities that receive the most Yale-New Haven referrals.

That new communication has been eye-opening, showing differences between the hospitals and SNFs that long had been overlooked. For example, SNFs typically have more restricted medication formularies than hospitals. "We are finding that the hospital can come up with a great plan, but the skilled-nursing facility can't carry it out because it's too cost prohibitive or can't be initiated promptly," Jenq says.

Several other barriers to successful transitions also have been identified:

  • Nursing facilities frequently do not receive the information they need to properly care for patients discharged from the hospital. Hospital clerical workers often do not recognize all the components of the discharge paperwork; historically, there has been no protocol for laboratory results, such as urine cultures, to be sent to nursing facilities.
  • SNF nurses do not know how to get information from the hospital. "Sometimes the nursing facility will call back to the hospital, but the hospital RN they reach will say, 'I don't know the patient,' and essentially end the conversation there," Jenq says. "We are going to have to lay out roles and responsibilities for all the people involved in the transition of care to make sure they are held accountable for this type of communication."
  • When a problem arises, nursing facilities may not share the hospital's goal of keeping patients out of the hospital. "Right now, the skilled-nursing facilities don't get penalized for the readmission, so they are not affected if the patient goes to the emergency department and gets admitted," Jenq says. "In the future, when penalties apply to them as well, both the SNF and the emergency department will be forced to develop care plans that can work at an SNF."

When Yale-New Haven launches a new electronic health record system this year, SNF staff will be able to access patient data, which should improve care coordination. Beyond that, Jenq says relationship-building between the hospitals and SNFs is essential to her goals of reducing readmissions and improving patient satisfaction.

"That is success — really working to try to develop a relationship and decrease the readmissions at the same time," she says.

Improving Communication

In Minnesota, Allina Health employs a team of 48 full-time equivalent physicians and nurse practitioners who make house calls in assisted living and skilled-nursing facilities, and are on call for consultation around the clock.
But that staffing does not, in and of itself, prevent gaps in care when patients transfer from one setting to the next.

That's why Allina last year launched a pilot project to improve the patient hand-off from hospital to facility and from facility to home, says Pat Peschman, R.N., director of Allina SeniorCare Transitions. The pilot is with a single SNF. Allina has seen a nearly 50 percent decrease in all-cause readmissions, as well as those deemed to be preventable readmissions, over the last 12 months. Statistical analysis is under way to determine how much of this drop can be attributed to specific aspects of the pilot process.

The work started with a rapid process-improvement exercise to evaluate the current steps in a patient's transition, identify gaps in care and discover root causes. Participants found various disconnects, including occasional disagreement about whether patients were being discharged to SNFs too early and an absence of clinical specifics for caring for those patients.

In response, Allina redesigned its discharge order set to make sure that SNFs receive all the information they need presented in a format that complies with SNF regulations. Pharmacists were recruited to help with medication reconciliation when a patient is discharged. Allina is using predictive modeling to identify individuals at high risk of readmission. Those patients are subject to an interdisciplinary discharge conference that focuses on removing barriers to a safe transition.

Beyond that, Allina and the SNF each assigned a nurse to help smooth transitions from hospital to nursing facility. The two communicate about patients who will be transferred.

"This allows our clinical nurse specialist to educate that transitions nurse [from the SNF] on the specifics of the patient's care that may be hard to communicate in the discharge summary format," she says. "The transition nurse may actually visit the patient in the hospital — that's what we're striving for — to help the patient and family really understand the environment they are going to, what they can expect to happen in the skilled-nursing facility, what the care will be like."

Coaching Patients for Success

Meanwhile, Henry Ford Macomb Hospital is using a health coaching model to help its high-risk patients make a successful transition from a hospital to a nursing facility.

"This addresses the simple fact that we do not have enough resources within our industry to positively impact patient behavior to the extent that we need," Schut says. "Patients must begin to embrace responsibility for their health, and this coaching model helps give them the tools to do that."

In this program, care transition coaches employed by the local area Agency on Aging visit Medicare fee-for-service patients who meet certain criteria — a diagnosis of congestive heart failure, chronic obstructive pulmonary disease, pneumonia or heart attack, or a hospital readmission in the past 90 days — to encourage them to enroll in the coaching program.

Patients discharged to their homes receive coaching on how to access community services and advocate for themselves when dealing with outpatient providers. For patients who go to a nursing facility, coaches provide intensive transition services for 96 hours. During this period, the coach helps patients and their family members know what to expect at the SNF, spots and fixes communication gaps between hospital and SNF staff, and makes sure the necessary discharge information is provided to the SNF.

Using personal health records and educational materials, the coaches educate patients to help take responsibility for medication reconciliation, physician visits and recognizing red flags that indicate their status is deteriorating. Schut says the approach is appropriate for frail long-term SNF residents as well as short-term rehab patients.

The coaches work only with the nursing facilities with very high readmission rates, agree to share relevant data and are willing to work jointly with the hospital to address systemic problems that lead to readmissions.

"This takes our perspective to a micro-level — one patient at a time — and we're getting much more insight into where the breakdowns are, and how we can facilitate improved care with various providers and transfer some of the responsibility to families and patients," Schut says. "And it's responsibility they want. They just don't know how to go about it."

Lola Butcher is a writer in Springfield, Mo.

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