Thanks to the U.S. healthcare system’s ongoing focus on delivering the “Triple Aim” of improved care, improved health and reduced costs, patient transitions have become more important than ever. 

Yet one of the greatest challenges for healthcare providers — particularly those in long-term care — is that as residents move from one site of service to another, gaps arise, notes Christopher Krause, director of rehabilitation for It’s Never 2 Late. 

Transitions are clearly something that needs more attention by everyone involved with long-term care, experts agree.

“Too often, when a patient leaves the hospital after a total hip replacement and heads for a short-term rehab stint at a skilled nursing facility, all of the documentation and information on that patient’s status doesn’t come with them,” he explains. “So they have to go through another whole battery of tests once they reach the post-acute setting.”

That’s a waste of time and money, says Kristy Brown, CEO and founder of Centrex Rehab. Mary Van de Kamp, senior vice president of quality at Kindred Rehabilitation Services, agrees and says therapy providers can and should serve as facilitators in supporting patients as they move through the continuum. This commitment to improving quality effectiveness and efficiency is needed in today’s era of accountable care organizations and bundled payment models, where the goal is to reduce cost while still maintaining quality care, she says.

“If a therapist communicates directly to the therapist at the receiving site, everyone is able to provide an improved patient experience, and it helps decrease redundancy in our planning and treatment,” Van de Kamp says. 

Tailoring interventions

As hospitals reduce length-of-stay and move patients into rehab and skilled nursing facilities sooner, post-acute care settings are facing an acuity level that they haven’t experienced before, says Mayaan Wenderow, director of marketing at EarlySense Inc.

“Long-term care and rehab facilities have to be ready for this because the last thing they want to do is have to send a patient back to the hospital,” she says. 

This might mean installing fall prevention technologies that allow providers to set different motion sensitivity levels on patient beds.

“With some patients, you just want to know that they’ve left the bed and are wandering, and an alarm goes off after they’ve been out of bed for 15 minutes,” she says. “But for some patients, you actually want to know when they lift a shoulder, so that nurses can make sure to get to them before they try to get out of bed by themselves.”

Taking a personalized approach is also important when it comes to determining what type of transitional care center to send a patient to once his or her acute needs have been met, says Cheryl Phillips, M.D., senior vice president of public policy and advocacy at LeadingAge.

“Many patients have comorbid burdens of illness and functional and cognitive impairments as overlay,” Phillips says. That means completing a thorough assessment of every patient as they prepare for discharge from acute care, taking into consideration the individual’s cognitive and functional levels, as well as their goals of treatment.”

“As we move toward bundles and ACOs, part of the worry is that the discharge planners will be focusing on the lowest level of care with the least variation in service and the lowest appropriate intensity of services,” she adds. 

One hope is that the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) will mitigate much of this by helping facilitate selection of the most appropriate care setting during a patient’s referral process, she notes. But it still behooves providers, patients and families to advocate to exchange information during every care transition, and includes a patient’s medical, functional, social and environmental situation, as well as his or her treatment goals, before determinations on level and intensity of service are made, Phillips says.

“The keys to good care transitions are a prepared patient and family, information sharing between settings of care and sharing goals of treatment so that everyone knows exactly where we’re aiming,” she says.

‘Warm hand-offs’ needed

Another way to help keep everyone on the same page is establishing a nurse transition coordinator role, believes Diane Vaughn, RN, C-DONA/LTC, LNHA, senior vice president of clinical services in a long-term care health system and a former consultant for Pathway Health Services. 

“In order to make all the gears work and ensure a safe and secure discharge for patients, you really need warm hand-offs whenever possible,” Vaughn says. A transition coordinator can make sure this happens as patients leave the hospital and move into a transitional care unit, and provide a familiar face to help raise confidence among patients that their care is aligned. Bedside care conferences, where nursing and therapy meet weekly with each patient and their family right in a patient’s private room, empower patients to be involved in the development of personalized therapy and nursing goals for discharge, she says.

It’s also imperative that a facility’s rehab director, MDS coordinator and director of nursing meet weekly to discuss every patient’s progress, says Paul Riccio, vice president of finance and development at Vertis Therapy.

“That basic level of communication is more critical than it ever has been before because if nursing and therapy are in two different worlds from a cognitive and ADL perspective, it’s going to affect facilities from a payment perspective,” Riccio says.

Getting substantial, accurate clinical information on each patient also will be required for proper coding during the transition to ICD-10, says Leigh Ann Frick, PT, chief clinical officer at Heritage Healthcare/HealthPRO Rehabilitation.

“In many cases, length of stay is half of what it used to be, and that requires therapists to prioritize their interventions with the main goal of getting the patient as safe and functional for the next level of care — but not necessarily to their highest functional level — before discharging them,” Frick says. ACOs need confidence there is a plan for the patient that takes into consideration all aspects of the discharge plan, she adds.

Follow-up contact also goes a long way in ensuring patient satisfaction and success, says Mark Besch, vice president of clinical services at Aegis Therapies. Vaughn agrees, adding that as state and federal guidelines continue to evolve, facilities need to focus on thoughtful and discerning discharge planning. That might include setting up a patient’s transportation or a Meals on Wheels service. Putting in a follow-up call to a patient 24-to-72 hours after discharge — to be sure their oxygen was delivered or their medications were picked up or their home health provider stopped by — can help reduce re-hospitalizations, she says.

It’s all about care partners valuing the part each plays, says Melissa Purvis, MSN, RN-BC, NHA, national director of clinical practice at Golden Living.

“Transitions happen best when we focus on the patient experience and outcomes,” she says.