Competitors Collaborate in SNF Care Coordination Network

Competitors Collaborate in SNF Care Coordination Network

Summa Health System’s partnership with dozens of SNFs proves competitors can partner to address a common goal — in this case, reducing adverse outcomes from poorly managed transfers and sharing accountability for the care of these patients.

Summa Health System reported that its SNF Care Coordination Network is reducing length of stay and mortality rates and improving outcomes for patients transferred between hospital and skilled nursing facilities during Improving Transitions of Care Between Hospital and SNF: A Collaboration Supporting the Accountable Care Vision, a webinar sponsored by the Healthcare Intelligence Network.

In case you missed this webinar, you still have a chance to hear this highly-rated program.

Register to listen today or order your training DVD or CD:

Improving Transitions of Care Between Hospital and SNF: A Collaboration Supporting the Accountable Care Vision

The steps leading to the creation of the SNF care coordination network are a boilerplate for healthcare partnerships — from the development of the RFP and task force to the introduction of the network to the health system, according to Carolyn Holder, manager of transitional care for Summa Health System, and Michael Demagall, administrator of Bath Manor & Windsong Care Center, an SNF participating in the network. Both shared the challenges and details of the partnership and early results from this venture.

The network targets some of the key breakdowns in the transfer process, including incomplete patient assessment, lack of patient data and communication barriers between staff members, departments and sending/receiving entities. Program highlights include the introduction of a Physician Orders & Transfer Form to standardize transfers and the use of staff scripts to overcome patients’ and caregivers’ resistance to SNF care.

The goals and outcomes of the program — which include reduced admissions, readmissions and ED visits by this vulnerable population — also fit neatly within the definition of accountable care and the IHI’s Triple Aim initiative.

Holder and Demagall shared with webinar participants:

  • How to create a win-win for SNFs and hospitals to reduce readmission rates;
  • Three key areas that negatively impacted care transitions between Summa’s hospitals and SNFs in its community;
  • Strategies implemented by Summa to address the key hospital-to-SNF transition challenges;
  • How to develop a QI process that monitors transitions on an ongoing basis to identify weaknesses in the care transition process; and
  • How the partnership is being developed and enhanced as the hospital system works toward development of an ACO.

You'll also get to listen to the question and answer session to hear information-sharing strategies in the absence of technology and with technology in place, how the collaborative approached reimbursement changes, the different roles of the interdisciplinary team in caring for the SNF patients and the program’s impact on SNF length of stay.

You can "attend" this program right in your office and enjoy significant savings — no travel time or hassle; no hotel expenses. It’s so convenient! Invite your staff members to listen to this conference. We will send you a DVD or CD-ROM of the conference proceedings or a link to our web site with a username and password. You can log in and listen to the program right from your computer — any time of the day or night, whenever convenient for you and your colleagues — and benefit from the archived recording of the conference, including the Q&A period.

To register for the on-demand re-broadcast of Improving Transitions of Care Between Hospital and SNF: A Collaboration Supporting the Accountable Care Vision or order the training DVD or CD-ROM, please visit:

I hope you find it useful.


Melanie Matthews
Executive Vice President
The Healthcare Intelligence Network