Renee Kinder

Transitions in care can be difficult, they can be scary, and when not coordinated appropriately they can be downright dangerous.

So what are the steps we need to consider when transitioning individuals across care settings?

Step One: Understand the setting specific reimbursement structure and outcomes measures

For those of us who live and breathe post-acute care spectrum care, we have been patiently watching the regulatory changes associated with IMPACT develop and appear to merge magically into greater levels of standardizations.

Exciting, right?

We appreciate that the Patient-Drive Payment Model presents similar themes and structure to the Home Health PDGM model and the fact that we also see a greater level of consistency in functional outcome standardization across the IRF-PAI, MDS and OASIS, including Section GG functional status and Section C BIMS.

More importantly, however, than the models and the measures themselves, we need to understand how we structure care to safely progress our patients across the care spectrum.

Step Two: Recognize the impact of timing, functional abilities, and the need for caregiver engagement

Personally, I am experiencing the struggles of baby chick transitions from care provided daily in-home to the transition to an outdoor coop.

Why did we decide to add chicks to the mix?

The eggs, of course! They are a favorite in our house, and in any form.

Hard boiled, fried, scrambled or diced in egg salad, they are served daily for breakfast or an after school snack. I highly recommend their protein goodness for keeping hungry kiddos and hungry husbands tided over between meals.

The only problem? In one setting, a dozen eggs is suddenly gone.

The solution was to welcome six silkie chickens to the family. We ordered five — one for each kiddo — however, much to my surprise when I arrived at the local post office, we were granted six precious little fuzz balls, chirping away, in a small cardboard box sitting on a hot hands pack for warmth.

Currently, we have four holding strong.

Like when we as caregivers navigate transition planning, I have had to initiate conversations with the kids about how it is time to move their chicks to a more appropriate setting outdoors.

They have clearly outgrown the makeshift bunny cage we have set up in Joseph’s room; they are starting to spread and flap their wings, trying to roost on their heating plate, and they simply need a greater freedom of movement.

Naturally, the kids are not convinced Mom has the chicks’ best interest in mind … What if a fox eats them? And what about the neighbor’s cat? And our dogs, or that snake we saw in the yard today?  

To combat their concerns, we have been allowing “outdoor chick play time” and wouldn’t you know, seeing their chicks run, explore, interact with neighbors, and attempt to fly instantly eased their fears.

“Wow, Mommy! Look how fast blue butt is! He is much faster than pink/red butt!” (Yes, they labeled and named their chicks individually by coloring their backside feathers)

We have even experimented with allowing them to run free with the dogs. All successfully!

Step Three: Effectively communicate health and personal needs with the next set of caregivers in the spectrum

Now, because I know you are curious: Why did we decrease from six chicks to four?

Enter the equation a young visiting cousin who aimed to train two chicks how to fly by placing them on the trampoline.

They were too young, they were being forced to complete an advanced task prematurely, and I am just thankful only two chicks were smuggled outdoors and past Joseph’s ever watchful eye.

A similar theme was also noted in last week’s SNF proposed rule from CMS with, poor communication and coordination across care settings with communication being cited as the third most frequent root cause in sentinel events.

Additionally, failed or ineffective patient handoffs are estimated to play a role in 20 percent of serious preventable adverse events.

Final Step: Standardization

The last and final step to ensuring continued effective transitions in care is to seek standardization. Additionally, when in doubt, as I have been researching coop building and city regulations for roosters versus hens … reach out to experts.

The good news here for SNF providers is that CMS is seeking our guidance.

Per the Proposed Rule SNF QRP Quality Measures, Measure Concepts, and Standardized Patient Assessment Data Elements under Consideration for Future Years: Request for Information:

“We are seeking input on the importance, relevance, appropriateness, and applicability of each of the measures, standardized patient assessment data elements (SPADEs), and concepts under consideration listed in the Table 13 for future years in the SNF QRP.”

Areas of consideration include:

Assessment-Based Quality Measures and Measure Concepts

  • Functional maintenance outcomes
  • Opioid use and frequency
  • Exchange of electronic health information and interoperability


  • Healthcare-Associated Infections in Skilled Nursing Facility (SNF) — claims-based Standardized Patient Assessment Data Elements (SPADEs)
  • Cognitive complexity, such as executive function and memory
  • Dementia
  • Bladder and bowel continence including appliance use and episodes of incontinence
  • Care preferences, advance care directives, and goals of care
  • Caregiver Status
  • Veteran Status
  • Health disparities and risk factors, including education, sex and gender identity, and sexual orientation.

Here’s to starting our care transitions with the right measures, recognizing when those we care for need to spread their wings, communicating effectively across settings, and moving to a greater level of standardized care!

Renee Kinder, MS, CCC-SLP, RAC-CT, is Vice President of Clinical Services for Encore Rehabilitation and is the Silver Award winner in the 2018 American Society of Business Publishing Editors competition for the Upper Midwest Region in the Service/How To Blogs category. Additionally, she serves as Gerontology Professional Development Manager for the American Speech Language Hearing Association’s (ASHA) gerontology special interest group, is a member of the University of Kentucky College of Medicine community faculty, and is an advisor to the American Medical Association’s Relative Value Update Committee (RUC) Health Care Professionals Advisory Committee (HCPAC).