Short-term stay or respite care offers a great solution for seniors who are recovering from a hospital visit, surgery or other medical issue. While short-term rehabilitation is effective in addressing the acute medical issue that landed a senior there, there is a constant struggle to ensure they receive the support needed after they return home —because that support means the difference between staying home or returning to the hospital.
Although a senior may need time to recover, they may not meet the criteria to remain in the hospital. This causes a predicament, as they still may not be healthy enough to be transitioned directly back home. For this reason, a main goal of transitioning to a short-term stay is to rehab the patient to a point where they can return safely home and not be readmitted to the hospital. But skilled nursing facilities (SNFs) face a significant problem in providing adequate resources for senior populations, which is reflected in the data. Readmission rates for hospitalized Medicare enrollees has increased significantly in the past several years. According to the America’s Health Ranking Senior Report, there is also a significant rate of ICU use among the population.
Presbyterian Village of Hollidaysburg’s (PVH) skilled nursing facility (SNF) in Holidaysburg, PA, can be a model for other SNFs looking to reduce short-term rehabilitation stays, as we have reduced short-term stays for Medicare patients by 45%, while also reducing seniors with private plan’s stays by 55%. This indicates that PVH was more efficient in rehabilitating patients in a given time period than any other SNF in the area, receiving healthcare nonprofit Highmark’s No. 1 status out of 204 skilled nursing facilities in the region. Fortunately, PVH followed best practices that other organizations can replicate to improve short-term stay rehabilitation times.
Collaboration is key
The rehabilitation rates, which beat national averages, can be credited in part to PVH’s deep collaboration with the local health systems. Communication begins with any home health provider even before the patient’s release. PVH nurses and doctors coordinate with the patients’ current doctors and family members to discuss any challenges that might be faced, along with their progress. Studies have shown that multicomponent interventions and advanced care planning have reduced readmissions through enhanced communication.
Learn from the data
In addition to establishing a communication process, creating a process for collecting and learning from quality data collection is highly important. A survey from Black Book Market Research shows that only 3% of long-term care facilities have the capabilities for data assessment. Even with the electronic health records, the ability to use the data to have an impact can be a challenge, but something that skilled nursing facilities need to invest in. The data gathered for each patient’s stay helps provide insights that allow organizations to adjust accordingly, tackling problem areas.
We use data to track trends related to quality. Trends can be positive or negative, and as we identify a trend the team begins to boil down the numbers to get to a root cause — so we can then precisely respond to a problem. We use numbers for infection prevention issues, functional outcomes in therapy, identifying high risk for hospital readmissions, pain control and more.
We rely on our monthly CASPER Report and 5 Star Report (Quality Measures) from CMS to identify any trends that need addressed. Some other examples of practices we have found to be successful are: following up with patient several times post discharge to ensure success at home and prevent hospital readmissions, home med reconciliation, communication with the PCP prior to discharge, and having a transitional care manager manage the entire rehab stay from admission to discharge.
Put quality care over quantity
Despite what many people might believe, longer lengths of stay do not always translate into better outcomes for older adults. We know this because shortened rehabilitation stays and collaboration have been linked to better health outcomes for seniors when the time is properly utilized. Studies show that when rehabbed appropriately, with the correct support when released, patients with a shorter course of rehabilitation and discharged to the community successfully were less likely to experience a 30-day hospital readmission. PVH aims to make the most of a short-term stay by providing this appropriate support, tailored to the specific needs of a patient.
Just as no two patients are alike, no two SNFs are either. But across the board, there are universal tactics all short-term stay rehabilitation centers can learn from. We know that collaborative communication, a data-based approach and prioritizing quality care over long-term stays go a long way to improving the short-term rehabilitation experience for older adults, their families, caregivers and medical professionals.
Stephanie Adams is healthcare administrator at Presbyterian Village at Holidaysburg in Holidaysburg, PA.