6004 – Collaborating on Care Across the Continuum
CHSGa is an integrated health care delivery system that offers access to a wide range of comprehensive health services and programs, from skilled nursing care to transportation services using state-of-the-art technology and equipment. Our Transitional Care Services member organization, Next Step Care, partners with our Skilled Nursing Services member organization, Ethica, to provide patient-centered care coordination to our patients as they transition back to the community. With the evolution in health care, increased patient acuity and shorter lengths of stay are occurring. To address the increase volume of higher risk patients transitioning to home, the Enhanced Transitions of Care model was birthed. This model is designed to serve as a transition safety net for high risk patients transitioning back to the community. With this pilot project, Ethica developed a risk assessment tool to identify high risk patients. There are delineated steps that occur on admission, during admission, and at the time of transition to home. Once Next Step Care is notified regarding this high risk admission, we are present at the 72 hour care plan meeting in the skilled nursing center. We build relationships with the patient and family and we are present on the day of discharge to home. Next Step Care then follows a 30 day follow-up protocol from day of discharge. This includes a combination of telephone calls and home visits. The number of patient contacts by the Case Manager varies based upon the variances/goals not met. The benefit of our Enhanced Transitions of Care model is that it has decreased hospital readmissions and emergency room visits post Skilled Nursing Facility discharge. It has also improved patient outcomes. In addition, this partnership allows us to closely monitor customer satisfaction and identify any service gaps while enhancing overall patient care.
1. Identify strategy to avoid rehospitalization and emergency room visit following discharge form skilled nursing center
2. Identify a high-risk patient through relevant predictors and activate an interdisciplinary approach to transition of care
3. Recognize “red flag” warning signs and follow up appropriately with patient, family and others