Guest Columns

Consider transitional care to expand referral relationships

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Ryan Sparks
Ryan Sparks


Identifying ways to improve census is a common goal among long-term care providers. Despite a continually expanding elderly population, occupancy levels are at the lowest point in five years. Why?

Numerous factors may be contributing to the decline in occupancy, including the growing role of managed care, alternative payment models that drive patients directly home from the hospital, and hospitals trying to avoid Medicare spend per beneficiary penalties. Still, senior care operators are not without options. Implementing a transitional care program can address occupancy challenges and may help regain market share in a continually narrowing market.

The importance of aligning with your referral partners

When developing your transitional care program, remember that you want to complement the efforts of your referral source, not duplicate them. Soliciting feedback from your referral partners can ensure you are incorporating the right activities and collecting the pertinent metrics for your mutual patients.

Another thing to consider is reporting back specific data to your referral partners in order to provide valuable patient insight and underscore your successes. The following list includes examples of the types of data you may want to report back.

  • Outcomes of Interventions: Demonstrate the outcomes that your team is generating through key performance indicators and outcomes data not available to your referral partner. For example, hospitals often see only the actual readmission totals, but you can provide new insight by presenting the total readmissions prevented through interventions performed by your team.
  • Population Health Trends: Responses collected from patients can provide important information about patient behavior, such as care plan adherence after the patient has returned home. This data can also help to identify the root cause of challenges that may occur after discharge regarding specific providers and medical service vendors.
  • Care Spend Benchmarking: Data on the utilization of post-acute care services collected from the transitional care team is a key indicator when determining the total spend of each patient. This data can be compared against target benchmarks and by diagnosis-related group (DRG) to clarify where post-acute network utilization targets are being achieved.
  • Success Stories: Quantitative data is expected, but qualitative data is also well received. Short examples of specific interventions show you are extending the same level of care for your mutual patients and provide insight into specific examples of your team's transitional care efforts.

Getting started: Know your market

When laying the foundation for your transitional care program, it helps to begin with an analysis of your surrounding market. A little research can help you identify referral partners that may be included in accountable care organizations (ACOs) or alternative payment models where your program may help reduce spend and network leakage. Reach out to nearby hospitals that have started or plan to start requiring post-discharge follow-up. Or, if you know of hospitals in your area that may be narrowing their referral networks, having a transitional care program in place may put you in a more favorable position.

How will you engage?

One of the biggest decisions you will face when putting together a transitional care team is deciding who will perform the patient follow-up activities. After weighing the costs and benefits, you may want to consider outsourcing your transitional care calls to a centralized call center. Such a system will often combine live calls with automated calls and optimize the use of lower-cost, non-licensed staff for the majority of activities needed. That way, your clinical personnel are engaged only when patient issues escalate.

Recognizing the value of transitional care

Faced with the current occupancy challenges, there are steps that senior care operators can take to build and cultivate referral relationships and strengthen their position in the market. Hopefully this article sheds some light on the benefits of implementing a successful transitional care program to address key concerns and help your facility stand out.

Ryan Sparks, MS, MBA, is the co-founder and chief revenue officer of Nexus Health Resources.


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Guest Columns

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