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Transforming PAC through SNF, ED and hospitalist collaboration

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Benjamin Frizner, MD Director of Quality and Performance, CEP America
Benjamin Frizner, MD Director of Quality and Performance, CEP America

Patients in post-acute settings are among the most medically fragile, with multiple co-morbidities that often require intensive care. The nature of their conditions makes them a leading source of hospital readmissions. In fact, approximately 15% to 28% of patients who are sent to a skilled nursing facility are readmitted to the hospital within 30 days.

Key reasons for these readmissions are poor coordination of care and minimal collaboration among post-acute care and hospital providers. This is why I developed the Post-Acute Care Collaborative — with the program goals of improving quality, outcomes and reducing readmissions, while also increasing patient satisfaction.

The main focus of the initiative was an effort to enhance collaboration with post-acute, emergency department (ED) and hospital medicine staff to focus on ways to prevent hospital readmissions. Encompassing coordination with principal members of the acute and post-acute care team, the program involves both the ED and hospital medicine staff of a community hospital in Baltimore, along with the care team of the nearby campus of FutureCare Irvington, a community skilled nursing facility.

The Post-Acute Care Collaborative targets the patients in the FutureCare Irvington ventilator unit, who are particularly fragile and complex. Most have been at the facility for six to 12 months following a complicated hospital course. Tracheotomies and feeding tubes are common in this population.

Throughout the first half of 2015, the ventilator unit had an above average number of readmissions per month. Many of these patients were sent back to the hospital for fairly routine issues like fever, abnormal labs or diarrhea. Frequently patients were admitted through the ED, adding additional burdens to an already busy department. Additionally, the health status of these patients often had a negative impact on the hospital's key performance metrics.

Many of these problems might have been managed at the local post-acute care facility had the right expertise been available.

One important aspect of the Long-Term Care Collaborative was that it created a change in practice culture, and increased acceptance of new protocols and systems. For example, a transfusion protocol for chronically anemic patients. Instead of admitting those patients to the hospital, they were sent to the ED during hours of the day when the census was lower, received their transfusion and returned to the SNF. The involvement of our program also helped set up discussions with patients and families regarding palliative care, helping to improve dialogue on this important step along the continuum.

Additionally, the Collaborative fostered a culture of teamwork, communication and collaboration between the SNF and the ED, versus a siloed approach to care.

Program results

  • As the program enters its second year, readmissions continue to decline. To date, readmissions have been reduced significantly. Most recently, there were zero readmissions the months of October and November.

  • The average patient admitted to the hospital had an average length of stay in the hospital of six days; all patients had tracheotomies and/or ventilator dependence. On average, those patients cost the hospital $2,000 per day. Prior to the Post-Acute Care Collaborative, 6.5 patients from the SNF were being admitted to the hospital each month. Under the program that number was reduced to 3 patients per month, or 18 fewer hospital days per month, resulting in significant savings for the organization.

  • The hospital also realized improvements in critical performance metrics including LOS, hospital acquired infections and mortality, as well as an improvement in the availability of ICU and intermediate care beds.

  • The SNF also realized cost savings. When patients are admitted to the hospital the SNF is not being compensated. When patients are cared for in the ED and returned to the SNF that same day, the SNF maintains the care for the patient and does not lose revenue.

  • Blended revenue for patients on the long-term care ventilator unit increased by 15%.

Program transferability to other institutions

The Post-Acute Care Collaborative is a simple-to-replicate initiative that can be readily transferred to any hospital affiliated with community-based SNF or long-term care facilities. The key is commitment and involvement from the ED, hospitalist and physicians in the post-acute facilities; strong communication with other team members, including nursing, case management and therapists; and a willingness to focus on how to integrate the program in a way that meets the daily demands of all members of the healthcare team.

With post-acute populations growing, the scope and magnitude of this type of initiative will continue to be of great interest to all healthcare facilities that recognize the need to break down silos and improve coordination across the care continuum.

Benjamin Frizner, M.D., FHM, has over 10 years' experience working in the hospital, outpatient, and skilled nursing settings. He was the Director of Hospital Medicine at Saint Agnes Hospital in Baltimore for four years before becoming the director of the long-term ventilator unit at FutureCare Irvington. Additionally, he serves as the director of Quality and Performance for CEP America.


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