Post-acute care providers can help hospitals prevent readmissions. But it will take a change in perspective and the formation of partnerships among care settings to improve patient care along a continuum.
On a shelf in my bedroom, I have a framed wallet-sized photo of myself and a smiling little boy with his head wrapped in a turban dressing of gauze and medical tape. I cared for him when I was a new nurse, not even a year into my career, after he had brain surgery to treat Landau-Kleffner Syndrome, a rare neurologic disorder.
His mother and I really connected, but after he was discharged I never saw them again. I still wonder how he progressed after the surgery. Was it effective long-term? Did he learn to speak? Was he able to attend school?
This "love-'em-and-leave-'em" approach to patient care has been pretty standard for decades. You take great care of patients while they're under your charge, but when they're discharged or transferred, your work is done.
But thanks to an increased focus on outcomes—both clinical and financial—the chasm between acute care and post-acute care settings is starting to narrow.
Rita Vann, RN |
Rita Vann, RN, chief clinical officer for Ascension Senior Living, who was head nurse on an orthopedic unit with a large number of patients with hip fractures, is familiar with the old approach.
"We did a lot of transferring and I just have this vivid image in my head of these little ladies being rolled out on stretchers with their transfer form lying on top of their chest," Vann remembers. "The extent of the communication that we had with, what is now known as the post-acute provider, was whatever we wrote on that piece of paper."
"We are [now] being held accountable for hospital readmission numbers with our partners and hospitals are being held accountable by CMS for their readmission numbers, so that is a shared quality goal that we have," she says.
Discharging the Discharge
While the "transfer-form mentality" still exists among some care providers, Vann says alliances between acute care and post-acute care providers are necessary to meet care standards.
"We really have to start building bridges between the two and making sure that we totally understand their role and that acute care totally understands what the next steps are for the patients they transfer to us," she says. "We need to work together to make that seamless."
Ascension has recognized that stronger partnerships mean better outcomes, and part of Vann's role is to cultivate positive working relationships between acute care and post-acute care providers.
One way the organization is shifting away from siloes of care and toward care that follows patients across the continuum is by phasing out the idea of the traditional discharge.
"We are working to get rid of the term "discharge" because if you look up the definition in the dictionary, it really is 'to get rid of, to stop,'" Vann says. "What we have to do is to transition that person from acute care to the next appropriate level of care."
That could mean a senior care community, a skilled nursing facility for rehab, or home with home care. But wherever that next setting may be, out of sight doesn't mean out of mind.
"I think that the key is understanding that even though they are leaving your community, your accountability for that safe transfer and safe transition does not end," Vann says.
I Want to Hold Your Hand
The goal of these partnerships is to create smooth handoffs between the various care settings. In order to achieve this, both sides must improve communication regarding patients.
"What I struggle to do every day is to make sure we have good communication with hospitals, that we're talking with our hospitals days before the planned transfer to know exactly what the particular needs of the resident are going to be," Vann says.
One way to do this is through the use of a clinical liaison who works with the hospital case managers.
"They will contact us about a potential referral and then we begin communication and making sure that that we can meet that resident's needs," Vann says. "We first have to make sure that it's a match and that we have bed availability to get them into our community. Then we work with them on making sure we have all of the information we need."
Vann points out this type of communication is necessary to minimize on-the-fly transfers that could leave a patient in situation that could set them up for a hospital readmission.
"Transition has to start the day they come in, because hospital stays are much shorter," she says.
"Unfortunately, we still see [instances] where we get a call in the morning for someone to be transitioned to our community that afternoon. Many times that is just not enough time for us to get the equipment or the medication in place that the person needs and to be ready to accept them on the other end."
Vann says that at a recent American Health Care Association meeting, healthcare consultant and noted long-term care advocate Mary Ousley, gave a description of patient transitions that resonated with her.
"She described it as a 'warm handoff,' where we're holding hands with the resident until someone else is holding hands with the resident so that the resident's hand never gets cold," Vann explains.
And it's not just a hospital holding hands with a patient until they get to a skilled nursing facility. Vann points out that transfers also occur from post-acute care providers to hospitals, or among different post-acute providers.
"It's imperative that we learn about the various levels of care and where we're transitioning patients and our residents," she says. "We can no longer discharge; it has to be a transition. It really is a true mindset change for all of us."
For more on creating partnerships between acute care and post-acute care providers, join Jesse Jantzen president and CEO of Ascension Senior Living for the HealthLeaders Media webcast, "How Ascension Senior Living Creates Successful Post-Acute Care Partnerships" on December 7 from 1:00–2:00pm ET.
Jennifer Thew, RN, is the senior nursing editor at HealthLeaders.