The healthcare system is under tremendous pressure to deliver efficient care to patients and move them along the continuum as quickly and safely as possible. Still, too often, transferring a patient from acute to post-acute care results in less than optimal outcomes.
In this webinar session, “Bridging the gap: Effective transitions of care,” sponsored by TeamHealth, Suzanne Powell, vice president of performance improvement for TeamHealth, and Roy Sittig, MD, regional medical director and acute to post-acute program national steering committee member at TeamHealth, offered strategies post-acute facilities can adopt to better align their practices with hospital standards for seamless patient transfers.
“Anytime that you have movement of a patient within the hospital, there’s a chance that some information could get lost and the quality of care delivered to the patient could suffer as a result,” Sittig said. “When we think about transitioning out of the hospital into the post-acute setting, the same issues apply.”
“One in five Medicare patients who were admitted to acute care in the hospital utilize post-acute services in a skilled nursing facility,” said Sittig. Nearly a quarter of those patients are readmitted to the acute care hospital within 30 days.
Sittig cited a Clinical Interventions in Aging article which revealed that, of patients readmitted within 30 days, 78% of cases were attributable to five different diagnoses: congestive heart failure, UTI, upper respiratory infection, sepsis or electrolyte imbalance.
“Those are five areas where we could potentially intervene to provide better care,” he said.
“Those readmitted patients have a higher mortality rate at 30 days and at 100 days. It’s associated with a quadrupled mortality rate within six months,” he added. “There’s no question that returning to the hospital often leads to poor outcomes.”
A focus on effective hospital partnerships
Facilities that better align their practices with hospital standards for seamless patient transfers and form strategic partnerships with hospitals can enhance care transitions and improve patient outcomes.
One of the key problems with transfers, noted Powell, is the lack of clinician involvement.
“About 90% of the time, the only people in the room are administrators and nurses, not the people making clinical decisions,” she said. “We all know healthcare is a team sport. We block and tackle as a team, but we need to create system improvements as a team as well.”
“Having clinicians at the table dealing with issues around quality and transitions is crucial,” Sittig agreed. Clinician inclusion is part of TeamHealth’s multidisciplinary approach to improving the patient transition process.
Powell suggested staff at skilled nursing facilities take a strategic approach to understanding the challenges and the goals around their transition process. She recommends including medical directors as well as post-acute liaisons, project managers, administrators, and others to discuss where a facility needs to focus its efforts.
“A first meeting should include a multidisciplinary team,” she said. “You’re going to have some bi-directional communication about what those goals and challenges are.”
Once the post-acute organization gets a clear understanding of what is working well and where it needs to improve, an action plan can be developed. Powell said an action plan should include four elements: identifying the problem that needs to be solved, creating an action plan for solving the issue, identifying the professional responsible for implementing that plan and setting a timeline. Powell stressed the importance of creating SMART (specific, measurable, achievable, relevant and time-bound) goals and keeping a scorecard of results.
Showcase stellar performance
As many systems and hospitals form preferred provider networks, creating a scorecard that tracks quality metrics can be an effective way to showcase performance.
“You don’t have to be good at 10 things. Make sure you’re good at three, such as wound care, cardiology, behavioral health, and that you have measures around those,” advised Powell.
Disseminating that information to the hospitals and patients is key.
“Many times, patients pick a facility based on geography only. If you can enhance that discussion with markers of quality, you can provide patients with good choices,” Sittig said.
Powell also recommended creating strong working relationships with the hospital medical director to encourage open communication and encourage collaborative problem solving.
“There should be one phone number acute facilities can call to help facilitate clinician-to-clinician communication,” she said.
Since communication is a big driver for quality of care as patients transition from one setting to another, Powell urged professionals to be “cultural brokers and silo breakers.”
“Leaders can help teams connect and relate to people across organizational divides by asking the right questions,” she said. “Asking open-ended questions helps you understand what the challenges are and allows you to be open to possible solutions.”
“When we ask questions with curiosity and without judgment, people feel safer to give us real feedback and discuss some of their pain points,” she added. “Try to ask questions in the least biased way and encourage people to dive more deeply into those specific issues. The art of inquiry is always asking each other why.”
The objective, added Sittig, is to ask the kind of questions that allow you to be “inquisitive about the system and come up with better solutions.”
