Guest Columns

Exploring transitions in care

Brian White
Brian White

Transitions in care, such as moving a patient from the ICU to a step-down unit or to a long-term care facility, are pivotal points that can impact hospital outcomes and patient satisfaction, as well as outcomes. These challenges can range from managing medications to knowing a person's complete medical history to understanding where to call and what to do if the patient has medical complications.

As the president of an acute care hospital, as well as overseeing our medical system's post-acute division, I see the issues facing our frailest patients from both sides. I see patients receiving great care in our hospitals, but when they leave us to go home or to another facility, we may not have the opportunity to participate in their transitional care.

But in today's healthcare environment, acute care hospitals are being held financially responsible for what happens to our patients after they walk out our doors. We believe it is important to seek new and better ways to continue to participate in our patients' care, even after they leave our hospital settings. We have been looking to find ways to shift the care delivery model by developing a new system to decrease transitions and break down traditional barriers, with the goal to decrease readmissions, improve patient and family satisfaction, and ultimately to improve outcomes. 

While we talk about numbers and outcomes and patient satisfaction, at the end of the day, we are talking about people. It's about what we can do to decrease or eliminate these all-too-common issues during transitions of care, which can have such a crucial impact on a person's health and recovery.

At LifeBridge Health, we believe we can tackle these challenges. We are a regional health system in Maryland with two acute care facilities: Sinai and Northwest hospitals. We also have Levindale Hebrew Geriatric Center and Hospital, a 356-bed chronic hospital and long-term care center. Our system also offers a complementary continuum of care from primary care, prevention and wellness to ambulatory care and post-acute care and nursing facilities.

The biggest challenge in succeeding in the new healthcare environment is figuring out ways to align an historically unaligned delivery system. At LBH, our largest source of readmissions was patients discharged to nursing homes. Even our own nursing home had a very high readmission rate to our acute hospitals. So, we asked ourselves: What was the root cause that created this recurring problem?

After talking to doctors and reviewing contract language, a fundamental disconnect rose to the surface. Our providers had conflicting incentives. Hospital-based providers focused on care delivery within the four walls of the hospital, while SNF-based providers were paid on productivity with no relationship to readmissions or other quality indicators.

Our first step was to collapse the existing structures, revise existing incentives and compensation models, and replace those under a common structure with aligned incentives focused on a smooth transition of care and shared accountability for the entire continuum of care.

The result: We saw a reduction of readmissions from Levindale by nearly 30% in less than one year. While we made great progress, we quickly realized that for LBH to be successful, we had to figure out how to align with those post-acute organizations that we do not own, yet shared thousands of patients with. Step one was to define post-acute quality of care metrics. We then created a post-acute collaborative with nearly 30 nursing homes tasked with meeting LBH's quality standards.

Then, we recently launched a new joint venture called Post-Acute Physician Partners. PAPP employs a roster of highly skilled primary care and specialty physicians, nurse practitioners and physician assistants who specialize exclusively in post-acute care, working as post-acute care hospitalists. PAPP is different than traditional nursing home management companies because its agreements include at-risk performance guarantees that meet or exceed those quality standards defined by LBH.

Soon PAPP will also employ specialists or sub-specialists who will see nursing home patients in their facility when appropriate, rather than sending them back to the hospital for treatment, minimizing another transition; use tele-health to monitor patients remotely and offer consults 24/7; and include a transitions-to-home nurse practitioner model.

At the same time, we have been looking at our patients going into nursing homes and we noted the increased medical complexity of patients being admitted into our chronic hospital. It was no surprise that these patients also had high readmission rates because when their condition changed or deteriorated, the patients were sent back to hospital — where all of the "resources" were. In our patient-centered care model, our emphasis is focused on bringing our resources to patients versus bringing patients to those resources. So, we created LifeBridge Critical Care, a team of intensivists who manage our system's sickest patients in our ICUs, IMCs and now in our High Intensity Care Unit in our chronic hospital at Levindale.

Today, one year after creating this group, we've seen improved outcomes, better efficiency and higher patient and family satisfaction. While we have made significant progress, we know that this is just the beginning, and there is much more work to do.

The shift in healthcare reimbursement has spurred this transition and need for cooperation across the continuum of care. With financial ramifications for readmissions, providers across the spectrum, from primary care to long-term care, now must focus on aligning their goals around quality, productivity, patient experience and stakeholder satisfaction.

During this time of change, we must go from disconnected to coordinated, minimizing the potential disruptions during transitions in care to provide the best care for our patients and ultimately improve the health of people in our communities.

Brian White is the senior vice president at LifeBridge Health and the president of Post-Acute Division and Northwest Hospital in Maryland. 

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