Guest Columns

Becoming the MVP of the post-acute sphere

Theresa Hartman RN, CCM Care Transitions Navigator
Theresa Hartman RN, CCM Care Transitions Navigator

Everyone is aware that the healthcare system for reimbursement is changing rapidly. Reimbursement will now be the driver of how we get our business instead of the reward for filling the bed.

How will reimbursement drive the business? Value Based Purchasing or simply stated payment for performance. All levels of care are now being measured on how we perform and those measurements will directly affect your reimbursement. Hospitals are already being penalized for all cause less than 30 day readmissions. Skilled nursing facilities will have 2% of their Medicare per diem withheld in 2019 to go into a pool that will later be distributed to the top performers based on CMS FY 2017 Proposed Final Rule.

This shift from Fee for Service to VBP and alternative payment models is all based upon incentivizing each level of care to deliver quality care, engage the patient in managing their chronic conditions and reducing escalating health care costs. Each player who passes the patient along to the next player in the healthcare continuum wants to be sure the downstream and upstream care giver is a top performer. 

Add to that Nursing Home Compare and other tools accessible to the public that show your performance and can be compared to the national average as well as the SNF down the road.

What is the magic bullet or secret sauce that will make you the SNF that outshines the rest?

A company supported culture change that creates a clear strategic roll out of a robust patient centered care transition program that includes evidenced based clinical pathways, direct communication mechanisms with hospitals and home cares, measurable goals and outcomes and solid accountability.

It's really pretty simple. If you take good care of the patient, are on top of them from the minute you get the referral and don't miss anything at admission or in planning the discharge and you add post discharge follow up, a patient has a much greater chance of being someone who will not end up as a less than 30-day readmission to the hospital and you will achieve better outcomes in all your quality measures.

However, before you can develop a program you need to step back for a second and think about the typical journey of a SNF patient throughout an acute episode. 

Let's take Mr. Jones, a typical elderly patient that becomes an admission on a busy Friday afternoon to your SNF. He had an unexpected acute episode related to a chronic condition not well managed at home. As our patients age they have less support from family and are reluctant to ask for help. The trip from ER to a SNF and then back home throughout an episode of acute illness has many areas of weakness that make our patients vulnerable to returning to the hospital.

The healthcare highway is made out of swiss cheese, filled with holes that swallow up numerous important things that fall into them along this journey. When Mr. Jones entered the hospital, no one likely ensured his medications at home matched the new medications they put him on to get through this acute episode. At discharge, chances are no one ensured the SNF knew everything that happened in the hospital. At the SNF everyone performed their assigned task, but there was no team that put Mr. Jones in the center and coordinated his care or discharge. There was likely little to no information given to the home care nurse or primary care physician about this acute episode.

Now it's time for the SNF to wave goodbye to Mr. Jones. They believe their work is done. 

They are unaware, until they get the call from the irate ER case manager a week later, that Mr. Jones' phone was turned off while he was in the hospital. The home care nurse never got to confirm a visit and he was never seen. His son called to check on him and the phone was out of order, so he planned to visit just as soon as he had time. There was no one to go to the pharmacy to pick up his prescriptions as it was just too hot out. When his son finally visited, he found his dad on the floor where he had been for some time, confused, dehydrated and back in heart failure.

As you look at Mr. Jones' journey, another scenario would be landing in the hospital directly from the SNF. His hospital paperwork could have been lost. There could have been a lack of communication that led to medication errors. He could have become anxious on admission. 

But how could this have worked better? The secret to becoming the MVP in your post acute network and the way to become the hospital's first choice, is making the commitment to creating a solid Patient Centered Care Transitions program. You must make sure this company wide initiative is embraced and supported by the CEO down to the CNA. 

A Patient Centered Care Transitions program will substantially mitigate your readmission risk, improve utilization management, improve your quality and therefore your quality measures, improve patient satisfaction and will improve communications with your upstream and downstream partners making your SNF a top performer who gets the business. 

Let's erase the old SNF care delivery model and start over by placing the patient back in the center and ensuring from referral to post discharge the transitions go smoothly.

Theresa Hartman, RN, is the Care Transitions Navigator at Mid-Atlantic Health Care.

Guest Columns

Guest columns are written by long-term care industry experts, ranging from academics and thought leaders to administrators and CEOs.

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