Never before have skilled nursing facilities had a greater stake in the CMS reimbursement process. For providers like Greystone Health Network (GHN), participating with Accountable Care Organizations (ACOs) and in Bundled Payment Care Initiatives (BPCI) have led to innovative approaches to patient care and raised the bar for clinical outcomes.
GHN understood that with the Affordable Care Act (ACA) greater emphasis had to be placed on improving the patient and family experience, improving the health of the population we were working with, and reducing costs to the Medicare and Managed Care Health plans.
One of the first steps GHN took was to establish the role of a transitional care coordinator (TCC) at its facilities. The TCC’s sole focus is on managing the patient throughout his/her post-acute stay, better preparing the patient for successful re-entry into the community. By doing so, the TCC is able to reduce length of stay and avoid returns to the hospital. This creates a quality outcome for the patient and ACO as well as the convener for the bundled provider for care improvement.
Through GHN’s care managers in the field, a determination is made at the first contact to insure that the patient is going to a facility with the right level of care. Once a patient is admitted, the TCC meets with the patient, his/her family and interested parties, and also connects with the patient’s acute care physician, post-acute physician and primary care provider (PCP) to ensure continuity of care. Through these communications, the TCC develops an appropriate transition plan.
The TCC’s responsibilities throughout this planning process are patient-focused:
– Review of current and past medical history
– Coordination of plan of care with interdisciplinary team
– Coordination of all services that will be needed in the community
– Scheduling of first appointment with PCP once discharged from SNF
– Reconciliation of medications with post-acute physician
– Securing bedside medication delivery prior to discharge
– Following of patient in the community for up to 90 days after discharge
To further improve the Transitional Care Coordination program, GHN has worked closely with Nexus Connexions on development of software that improves tracking and facilitation of transitional care once the patient has re-entered the community. While still in early stages of implementation, GHN is already recognizing the benefits of the electronic management on post discharge calls and follow-up activities.
GHN is also improving quality outcomes, increasing patient satisfaction and decreasing unnecessary, avoidable hospital readmissions with the introduction of Advanced Registered Nurse Practitioners (ARNP) to its team. The ARNP collaborates with the interdisciplinary team to identify early clinical signs that would lead to a patient to be readmitted to the hospital.
