In today’s healthcare environment, putting patients and residents in the right place at the right time is imperative, according to Kindred Healthcare leadership. Baby boomers are aging, creating a stress on the American healthcare system, and the government and healthcare organizations are calling for the management of patients at a lower cost. We are seeing moves toward reducing costly readmissions to acute care hospitals, and managed care and pay-for-performance models of healthcare delivery. There are currently 47.6 million Medicare beneficiaries with approximately 9,100 new beneficiaries added each day. To answer the call to lower costs, lengths of stay in acute care hospitals have been shortened, and as a result, skilled nursing facilities are being asked to do more. About 35 percent of Medicare beneficiaries discharged from acute care hospitals are transitioning to post-acute care.The adoption of integrated care and integrated payment models will focus greater attention on how well a patient’s care is managed as he or she moves through the healthcare continuum, from one care setting to the next. Incentives and reimbursement will be related to the entire episode of a patient’s care, from an acute care hospital, through a transitional care hospital, a skilled nursing facility, home health care and outpatient rehabilitation, as an example. We will see moves toward shared accountability in transition planning between settings of care and organizations; the need for efficiency; heightened awareness of patient safety and quality; mitigation of barriers, and the need for smooth and secure transitions of critical patient information.Transitions of care will become increasingly important and scrutinized. Hand-offs, including plans of care and medication administration, must be managed efficiently and well. According to the National Transition of Care Coalition, a consortium of organizations dedicated to addressing problems associated with the movement of patients from one practice setting to another, seven essential elements make up the care transition bundle, all important to effective management of care transitions:
An interdisciplinary care management approach is key to managing infection control and avoidable days; addressing flow barriers as patients move through different levels of care, from the hospital to transitional care hospitals, skilled nursing facilities, home health care or hospice care; and ensuring adherence to National Patient Safety Goals, as set forth by The Joint Commission, an independent, nonprofit, healthcare accrediting organization. Kindred’s Massachusetts Integrated Care Market is serving as a model for successful care transition planning, both for the organization and for the field as whole.“Our goal is to develop and implement a model focused on care transitions to promote seamless navigation of patients through the post-acute continuum and improve patient satisfaction and outcomes,” said Stacy Hodgman, Senior Director of Care Management for the Boston Integrated Market.Under the new model, transitional care nurses will be hired to follow consenting patients through Kindred’s post-acute continuum, and staff and physicians will be educated about the role of the transitional care nurse. Collaboration with primary care physicians is a big part of the transition from case to care management, said Ms. Hodgman. Transitional care nurses will be charged with calling the primary care provider with each transition of care. “The primary care provider will be involved every step of the way,” she said. Transitional care nurses will also be charged with improving patients’ self-management skills and enhancing communication between the patient, healthcare delivery teams and the patient’s primary care physician. The nurse will physically and telephonically follow the patient through the entire post- acute episode of care.As skilled nursing facilities begin to play a bigger role than ever before in the new healthcare landscape, Kindred and Kindred Nursing are well-positioned to meet new challenges. In Kindred’s Nursing and Rehabilitation divisions, 18 percent more patients have been sent home from 2008 to 2012, with nearly 53 percent of patients discharged home after an average length of stay of 30 days. From 2008 to 2012, we have reduced lengths of stay 26 percent in our nursing centers. As care transitions take on growing importance, Kindred is ready. Watch the below video to see an Admissions Director at Kindred talk about the excitement her team gets from helping patients with their care transitions.
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