As acute care providers begin to bear the financial risk for hospital care and post-discharge health, post-acute care providers are faced with a need for stronger case management systems, more patient touch points and consistent post-discharge management.
Traditionally, post-acute care providers have demonstrated their value proposition through traditional clinical metrics (i.e. antipsychotic utilization, resident falls, etc). Given the emergence of preferred provider networks and increased competition, those traditional metrics no longer provide an adequate representation of the complete patient experience, including the resident stay and post-discharge follow-up. Post-acute organizations that enhance their patient experience and provide better discharge follow-up data will be able to strengthen their overall value proposition.
At Wellspring Lutheran Services, our organization operates post-acute care services in both urban and rural markets. In both markets we have experienced an increase in competition, negligible managed care payment rates and the emergence of preferred provider networks. We have found that, in order to maintain our referring relationships and avoid penalties for re-hospitalization, there is a need to demonstrate post-discharge patient management within the 90-day exposure period and illustrate the patient experience for those patients choosing our organization.
In response to our acute care partners’ needs, we sought to develop technology that would aid in collecting patient feedback and extend our patient post-discharge follow-up system. Through internal strategic discussions, our organization realized that we needed to demonstrate our ability to manage our skilled nursing rehab patients post-discharge during the 90-day exposure period and enhance our post-discharge case management process.
We found that we had little to no contact with our rehab patients once they returned home and we were unaware of their recovery progress and issues that may have caused re-hospitalizations.
This technology has now taken the form of our WeCare Connect™ system. This system makes calls to our patients and asks them a series of general questions, along with specific questions tied to their primary diagnosis, at key recovery milestones, allowing us to meet extended patient needs and the goals of an evolving market.
When a patient managed through WeCare Connect™ is contacted via phone, email, or mobile app, all responses are stored in a proprietary cloud platform and automatically reported to key clinical leadership to track and resolve all patient issues. This technology allows us to increase client satisfaction, improve recovery outcomes and make us aware of individual patient issues to allow intervention and reduce re-hospitalizations.
During the initial 24-hour call, we were able to ask our discharged patients about their patient experience. These patient experience metrics play an integral role in our hospital presentations and provide input into how exactly patients view their stay in our facility.
During the rehab follow-up call process, our organization found that some patients, upon 48 hours after discharge, did not receive their home care and/or therapist first visit. Through being notified by the system, our key skilled nursing stakeholders were able to contact the home health care agency and patient in order to avert a potential re-hospitalization and ensure a successful discharge to home. We have since collaborated with our key home health agency partner to ensure our patients are contacted within 24-hours and their first visit is scheduled.
As acute care health systems seek increased patient experience, patient satisfaction, and clinical data, they are also paying close attention to how skilled nursing facilities manage the care of patients after their stay is complete. In many instances that expands beyond data collection and application into an encompassing patient-satisfaction model, as Kira Carter-Robertson, Vice President of Post-Acute Care Services for Sparrow Health System, explains: “When selecting skilled nursing facilities for our preferred provider network, we are looking for more than just the CMS star ratings. The clinical data tells a story, but we are paying closer attention to the patient experience, overall patient satisfaction data and how skilled nursing providers manage their patients post-discharge.”
As our organization began utilizing the WeCare Connect™ technology, we began to see improvement in recovery outcomes, increased patient satisfaction and a consistent case management process. What we found to be most beneficial was our ability to extend our care while gaining valuable patient feedback data. We also were able to avert potential patient re-hospitalizations, as the call system allowed us to ask specific questions related to their health needs.
After establishing the benefits of the WeCare Connect™ technology for our own facilities, we made the decision to begin offering the technology to our colleagues as well. EHM Senior Solutions, located in Saline, MI, is one of our colleagues who took a proactive approach in their post-acute care case management follow up by utilizing the WeCare Connect™ technology we developed.
Like our organization, EHM Senior Solutions took a proactive role in managing their patients post-discharge through the WeCare Connect™ technology. As part of their overall patient care management strategy, including taking ownership of the time their patient is outside of their building and providing more patient care touch points during the 90-day exposure period. “We are able to say to our acute care partners that we have some ownership in the post-discharge process,” says, Nancy Swierz, Vice President of Success Strategies for EHM Senior Solutions. “We do not get paid extra for this service, but it is part of our mission and we feel it is the right thing to do for people going back to home. We all have some form of responsibility for people to be successful at home.”
We have found through the WeCare Connect Technology™ our organization can better demonstrate its post-discharge case management process during discussions with hospital case managers and during the preferred provider contract and presentation process.
Thanks to its implementation we have averted multiple re-hospitalizations, weeded out poor home healthcare providers, provided enhanced education to our patients and ensured that our commitment to our patients extends beyond their stay in our facilities. These efforts have allowed us to provide better discharge follow-up data, enhancing our patient experience and creating, overall, a stronger value proposition.
Michael Logan, MHA, is the senior vice president and chief operating officer at Wellspring Lutheran Services.
