This Week's Challenge: Through a growing number of community partnerships with skilled nursing facilities, the Summa Health System Care Coordination Network has reduced hospital readmission rates and average length of stay for patients transferred to these SNFs and has positioned themselves well for development of an accountable care organization (ACO). We wanted to see the care coordination challenges of acute care settings addressed by the SNF Care Coordination Network.
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What We Learned:
"The first issue identified by the Care Coordination Network is the lack of quality information received upon transfer from an acute care to a nursing facility. Second is the lag time in identification of post-acute bed ability. This means that a social worker at that time phoned or faxed information over to a facility, which at that time probably took up to 24 hours to respond as to whether or not a bed was actually available. That person may have been ready that day and it would have postponed that discharge another day. Next we had barriers to the patientís acceptance of the need of post-acute care, meaning that social workers and care coordinators at the bedside were telling them, 'Itís time. We think you need some rehabilitation.' The next issue we had was the family expectations. In other words, does the family feel that they need to go to the 'nursing home?' The issue of the conflicting interpretations of the hospital staff and the insurers to spot the appropriate levels of care; one of the concerns we had from the SNF side was, ĎIs this going to send a lot of our patients and our referrals to home healthcare and decrease our referrals by participating in this?í That was not the case."
--- Michael Demagall
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Excerpted from Improving Transitions of Care Between Hospital and SNF: A Collaboration Supporting the Accountable Care Vision, a 60-minute webinar replay that shares how Summa Health System has reduced hospital readmission rates and average length of stay for patients transferred to SNFs through a collaborative Care Coordination Network and has them well-positioned as they work toward development of an accountable care organization.