Strategies for Post-Acute Facility Care Redesign

Highlights from Remedy’s Innovation Collaborative
October 1st and 2nd, 2015 |  Baltimore, MD

Eric Hume, MD, orthopedic surgeon and Director of Quality and Safety for Orthopedics at UPenn, described acute and post-acute care collaboration for joint replacement patients. He emphasized Collaborative Pathways– which specify interventions spanning a recovery period– to assure a safe transition between acute and post-acute care. Penn uses an Acute Transfer Tool to assure necessary information is included in the patient transfer such as:

  • pre-admission history and physical
  • the preoperative assessment by social work
  • a brief operative note
  • detailed therapy goals
  • medication list
  • labs within 24 hours of discharge

In order to establish clear recovery goals, his team is explicit in communicating to the post acute facility– as well as the patient and family– the functional metrics necessary for discharge home. Moreover, they have a pathway to avoid readmissions for suspected post-operative joint infection that includes a prompt surgeon office evaluation and specific lab criteria for admission. Finally, he emphasized a "Home Safely" care path created by Penn to facilitate transition to home from a skilled nursing facility or acute rehab after a joint replacement.

Jill Shutes, ARNP, Senior Program Coordinator, Interact T.E.A.M Strategies, discussed the INTERACT Quality Improvement Program, an evidence-based intervention to reduce unnecessary acute care transfers for skilled nursing facility patients. She described the program’s components, including care paths and tools for communication, decision support, medication reconciliation, advanced care planning, and quality improvement. She reviewed evidence from the Commonwealth Fund Project demonstrating facilities using INTERACT achieved a 17% relative reduction in all cause hospitalizations.

Walter Lin MD, MBA and CEO of Generation Clinical Partners discussed a structure for elevating skilled nursing facility (SNF) clinical performance. He outlined strategies to assist SNFs in performance improvement, citing physician/provider coverage and measurable quality of care as key criteria for entry into a performance network. Dr. Lin asserted that an ideal SNF medical practice includes physician/provider presence in the facility throughout the week, responsive night and weekend coverage, and remote access to patients’ medical records. These providers optimally see new admissions within 24 hours of arrival, risk stratify patients and see those deemed high risk daily, with a focus on treating in place and ensuring smooth transitions of care. He stated it is key to have physicians co-leading performance improvement meetings, engaging the medical and nursing staff through clinical leadership and representing the SNF on Joint Operating Committees with hospitals.