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Intelligence Report: Care Coordination Considerations

By Michael Zeis  
   September 02, 2015

The SNF environment can be a challenge for care coordination teams. According to Hines, "Even though it is extremely important to go to the right skilled facilities with the right skill sets and capabilities in order to keep that patient from being readmitted to the hospital, there's a big gap in coordinated care. We're finding that they have been understaffed and under-resourced. As a provider team, we're going to have to figure out how to extend our reach and resources to work hand in hand with skilled nursing facilities to engage them in management of patients." The survey results provide a perspective of the very gap Hines mentions. In spite of the industry's attention to SNFs, only 22% of acute care organizations are deploying clinicians to skilled nursing facilities.

Dayal acknowledges that healthcare leaders must examine where the borders with acute care are, not only with SNFs but also with community services. He asks, "Where does our responsibility end? Is making sure that someone is eating healthy and has access to food a healthcare system issue or a societal issue? When we start talking about a population, it's not like a hospital saying that when somebody leaves they're done. [Care is] so interconnected that it's going to require some level of understanding of how the different components connect together and where one's role ends and where the other's begins."

Indeed, although there is plenty of room for improvement among all settings, skilled nursing facilities occupy the bottom of the chart that displays how healthcare leaders appraise the strength of their organizations' care transitions, with just 55% saying their care transition with SNFs is sufficiently strong, and 42% saying they are not sufficiently strong. Nearby on the bottom of the chart are care transitions with outpatient primary care (41% not sufficiently strong) and outpatient specialty care (43% not sufficiently strong). And that may be only part of the story.

Newbrough cautions that not only should healthcare leaders consider the success of the transfers they know are occurring, but they must also develop a sense of whether their care continuum partners are, indeed, receiving the referrals they should. He uses palliative care as an example, noting that 64% of organizations report that their care transitions are sufficiently strong. "It could be that only one out of four patients who should be referred to palliative care or hospice are actually being referred," he says. "Generally, we don't have a strong process for identifying these patients and getting them into those palliative care programs."

Reprint HLR0815-3

Michael Zeis is a research analyst for HealthLeaders Media.

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