Community partnership reduces hospital readmissions by providing the right care in the right place at the right time.
Most patients, upon discharge from the hospital, are eager to return to the comforts of their own home. But for some, particularly the elderly or chronically ill, the transition to home can be difficult. Perhaps the stairs are too steep or the bathtub too hard to get in and out of, or maybe the family just can’t provide enough support. For any number of reasons, some patients are just not capable of staying in their home and need to be transferred to a skilled nursing facility (SNF), such as a nursing home or rehabilitation facility. However, the process can be stressful. A new program through Partners HealthCare at Home is seeking to ease some of the burden through direct referrals to SNFs.
In most cases, when it’s determined that a patient needs to be admitted to a SNF, they are sent to the Emergency Department (ED) and admitted to the hospital. Only after they have been evaluated are they sent to a SNF. It’s a process that can be stressful, costly and time consuming. But now, through PHH, patients who fail at home can skip the hospital and go straight to a SNF.
Director of Case Management at Brigham and Women’s Faulkner Hospital Nancy Schmitter, MS, BSN, RN, CCM, says, “Working with our community partners has proven to be an effective way to improve patient satisfaction and promote the right care in the right setting. This leads to a decrease in unnecessary readmissions and leads to a decrease in healthcare costs.”
The process is relatively easy too. When a patient is discharged to home from a Partners HealthCare hospital and referred to PHH (they may also be referred to PHH from outside the Partners HealthCare network), a clinician visits them at home to admit them to PHH. In most cases, the patient is admitted to PHH and home visits begin. If, over the course of a few visits, the PHH clinician finds that the patient is failing at home, the direct referral to a SNF process begins. In some case, the PHH clinician determines on the very first visit that the patient needs a SNF rather than home care and, rather than admitting them to PHH, refers them directly to a SNF.
Regional Director of Continuing Care for PHH and a member of the task force that developed the program Mary Beth Harney describes the process, “We rely on the PHH clinicians in the home to have a conversation with their clinical manager. The clinician in the home has assessed the home and knows what the issues are. They can determine if the home is not the appropriate setting at that time for all the reasons that it might not be. Since the goal is to keep patients at home, we have them talk to the clinical manager to see if there are more resources that we could add that would make staying at home safer and make the transition time better. If the clinician in the home and the clinical manager feel that a SNF referral should be entertained, they will contact the primary care physician. They have a conversation with the primary care physician about what they are finding in the home. At that point, the primary care physician makes the decision if he or she is comfortable with PHH going ahead with a direct referral to a SNF or if he or she would prefer to see the patient in the office or send them to the ED. We rely on the primary care physician’s clinical judgment at that point.”
PHH also works closely with the hospital from which the patient was discharged, the primary care provider and the SNF to which they are referred. The whole process needs to work well for everyone involved, especially the patient. Senior Director of Referral Operations and Business Development at PHH Shaune Barry organized the task force that figured out how it would work for all parties involved. “We included folks from across the system,” she says. “After multiple meetings, we had the parameters for the program set up, the workflow outlined and we had identified the key contacts to provide the service. Then we held internal meetings within PHH to roll it out to the clinical team. And it has been working very well.”
To date, the feedback from patients and families has been positive. And it’s also been good for the hospitals who work so hard to reduce readmissions. “The goal here is to avoid unnecessary ED visits and hospital readmissions by getting our patients into the right level of care at the right time,” says Barry. “
Patients who take this direct route to a SNF are usually admitted within 24 hours. However, because they are not typically urgent cases, the patient can choose to wait for a bed to open up at their preferred SNF, all the while being under the care of PHH. “It certainly helps case managers to know that when they did send the patient home, the plan didn’t fail, it just simply changed,” says Schmitter. “Patients have choice and every patient wants to stay in their home. They want to make it work. Sometimes it does work and sometimes it doesn’t. When they come to that reality that they need care in a skilled nursing facility, then this makes their next discharge to home a better experience.”