From Traditional to Transitional: Transforming the Post-Discharge Model

Ensuring continuity of care from the hospital to the post-acute care (PAC) setting has never been more critical. Making transitions safer and more effective can help patients recover faster and avoid a return trip to the hospital – and help providers succeed in the new era of readmission penalties and bundled payments, where they are held financially accountable for quality outcomes when patients leave the hospital.

Creating new programs for success

To deliver better patient outcomes, forward-thinking post-acute care facilities are transforming the traditional approach to post-acute care, one often marked by poor communication between the hospital and PAC provider and inconsistent clinician visits to patients – leading in turn to more patient trips to the emergency room and higher rates of hospital readmissions. They are instead testing alternative models through which new patients are seen within 24 hours of PAC admission and are then visited regularly by a clinical team that specializes in post-acute care.

For example, Texas-based StoneGate Senior Living, a leading provider of rehabilitation, skilled nursing, assisted living, and memory care services, recently launched the Spectrum model, designed to mitigate returns to acuity (RTAs). The model was created by Spectrum Healthcare Solutions, an Oklahoma-based group of hospitalists and physicians.

Dr. Senthil Raju, who serves as medical director at StoneGate’s Medical Park West Rehabilitation and Skilled Care center in Norman, Oklahoma, and its newly opened facility, Accel at Crystal Park in Oklahoma City, says the Spectrum program was pilot-tested at Medical Park West in October 2016. In just three months’ time, the facility achieved an RTA rate of less than 10 percent – a nearly 100 percent reduction in RTAs and the best results it has experienced to date.

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Closing the communication gap

A key obstacle to reducing RTAs, according to Dr. Raju, is inadequate communications between the acute and post-acute care provider, among the PAC caregiver team, and from the team to the patient. The Spectrum model addresses these gaps through a transitionalist physician, a nurse liaison, and a dedicated nurse practitioner, he explains.

“Transitionalists are hospitalists who work part of the time outside of acute care in a PAC facility. They can help providers improve patient care, reduce length of stay, and avoid financial penalties for preventable readmissions.”

The nurse liaison serves as a medical transcriptionist, he says, maintaining records on each patient and providing them to the PAC clinical team, including the nurse practitioner (NP). The NP sees each patient within 24 hours of PAC admission, which helps to reduce medication reconciliation errors – the most common avoidable issue when a patient transfers between different care settings. The NP also makes rounds with physicians, monitors progress daily, communicates with the patient’s family, and provides timely education to the PAC nurses and caregiver staff. “With continuous patient monitoring and consistent communication, we are better equipped to resolve issues onsite rather than sending the patient back to the hospital.”

Connecting care for better outcomes

“Transitionalists are like air traffic controllers,” adds Mike Beaty, StoneGate’s Vice President of Provider Relations. “They help connect the dots in the patient picture, resolve breakdowns in care, and improve transitional care outcomes. As a result, they can avert many of the challenges that plague post-acute care, from medical errors to lack of care coordination and unreconciled medications.”

In the StoneGate Spectrum model, Beaty explains, Dr. Raju not only serves as a transitionalist but also recruits specialists, such as nephrologists, infectious disease specalists, and cardiologists, so patients in the skilled nursing setting can have emerging needs met at the PAC facility without having to return to acute care.

Coaching staff to spot ‘red flags’

Beaty notes that the NP dialogues with patients so they know what’s happening to them every step of the way – and also coaches staff on patient issues. “Several times when I’ve visited Medical Park West, I’ve observed the NP coaching members of our clinical team, advising them on what they need to look for to avert potential complications. Because of this mentoring, our clinical staff are even more aware of, and accountable for, their shared responsibility for communicating clearly as a team and better coordinating care.”

Catalyzing the healing process

“Half of the patients at our facilities are still recovering from acute sickness when they’re admitted for post-acute care,” Dr. Raju explains. “They’re not only recuperating from what brought them to the hospital in the first place; they’re also at generalized risk for a range of adverse health events – a condition known as ‘post-hospital syndrome.’ It’s been suggested that the risks in the critical 30-day period after discharge are as much a product of impaired physiological systems – such as a weakened immune system, malnourishment, confusion, and sleep deprivation – as they are of the patient’s original acute illness. Most patients have started new medications and change medications in the hospital. These changes need to be closely monitored.” The PAC team can then intervene whenever a patient’s condition requires it, he notes.

Another side effect of hospitalization is depression. “Being bedbound in the hospital can quickly sink a patient’s spirits. Being admitted to a skilled nursing facility can cause even more depression, as nursing homes are often viewed as the beginning of the end.” Another benefit of the Spectrum model, Dr. Raju explains, is helping patients and families navigate the psychological aspects of post-discharge care and providing the support and reassurance that can catalyze the healing process – and a speedier return home.

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