Transitions Through the Continuum

In a recent HealthLeaders Media Intelligence Report, most healthcare leaders said the status of their care transitions for care continuum providers or services was sufficiently strong, but indicated that there was room for improvement. HealthLeaders Media Council members discuss where they are finding success in improving care transitions outside of their facility.

This article first appeared in the January/February 2016 issue of HealthLeaders magazine.

Mitch Fillhaber
Senior Vice President for Corporate Development and Managed Care
The Shepherd Center
Atlanta, Georgia

The Shepherd Center is a 152-bed specialty clinic that functions as a rehab hospital with its own ICU. We have one of the youngest rehabilitation populations in the country, and we have a significant MS population who uses our outpatient care facilities. The continuum is a bit different for us than at a typical acute care hospital, and our care transitions are inevitably more complicated.

For many years, we've had a transition-support program that manages the return of high-risk patients and their families to the community, whether it be here in Atlanta, elsewhere in Georgia, or anywhere across the country.

As our patients are discharged, we're assessing the follow-up providers' capability and, if needed, providing education that creates a secure care environment for our patients who are going home. We're also working to provide education to patients and families to make sure they can maintain a positive health status once they've returned home.

Sandra Bailey
Vice President of Care Transitions
Methodist Healthcare
Memphis, Tennessee

We've found that employing care navigators has improved care transitions in our facilities. Navigators utilize multiple strategies in their roles, including leading interdisciplinary care teams, meeting with families, and determining resources the patient will need when they go home.

We have an evaluation team that determines whether the patient will benefit from home care. If they will, their physician then talks to the patient and tells them that they've recommended home care for them. We find it's a more proactive way to address the situation.

We also have teams that meet with high-need patients, and then those patients have a comprehensive discharge plan that's developed along with the family of the patient. That is initiated at the beginning of the hospital stay, revised throughout the stay if the needs or condition of the patient changes, and then, at the end of the stay, is coordinated by the case manager and a social worker along with the patient and their family.

We are also working with local churches in several areas that high-need patients live in. These churches are offering to help families with their special needs.

Patient education is critical. Methodist Healthcare is partnered with the Mayo Clinic system, so we have access to its educational material that we can add to our own ongoing education for patients and their families.

Jill Barber
Director of Managed Care Operations
and Revenue Integrity
Southwest General
Middleburg Heights, Ohio

The seemingly counterintuitive answers to the survey don't surprise me. Everyone thinks that their continuum resources are sufficiently strong for how we have practiced healthcare in the past, but, as we get more involved in things—such as readmissions penalties, as well as being concerned about bundled payments and other alternative payment models—we're realizing that what has been good enough in the past is going to need improvement, or will no longer meet our needs at all.

We are really pushing forward in developing a preferred provider network for postacute care. In the near future, there are going to be rules about how postacute providers play within that network, how they join, how they receive referrals, and how they are also removed and replaced with another provider.

We are starting to realize that there's no one flavor of home health, there's no one flavor of skilled nursing, that one size doesn't fit all. For example, home health for a congestive health failure patient will be very different from home health for a patient with a knee replacement. We are trying now to coordinate a better postacute care model and care-continuum flow with a set process for each of our patient populations. We want to recognize that while also setting standards that providers must work within.

Terry Preite
Benefis Spectrum Medical
and Regional Relationships
Great Falls, Montana

On patient education: Educating patients is everything. We continue to modify our processes to incorporate more education throughout the patient's stay, and to our postdischarge programs. An example of that is our Safe Landing program, which is an extension of the discharge planning process. A nurse visits the patient's home and goes over the discharge instructions with them to ensure they understand everything.

On discharge planning: Discharge planning is no longer the last step in the process; it's the focus of the entire stay. What is this patient going to need when they go home, or go to their next level of care? We focus on patient education and on engaging patients in the healing process, both during and after their hospital visit.

On rural challenges: Benefis is the major tertiary center for a region that spans 40,000 square miles. Many towns in our service region have fewer resources available to care for patients. It's been difficult at times to ensure that patients returning to their homes have the support that they need. Improving communication with primary care providers in the patients' hometowns is part of this challenge. CMS recently awarded a grant to Liberty County Hospital—a member of our Northcentral Montana Healthcare Alliance—to work on improving care transitions to these small communities along with local critical access hospitals.