Value Based Care Benefits of Strong Acute and Post-Acute Care Collaboration

If there’s ever been a team sport in healthcare, it’s value based care.  As much as a healthcare organization thinks they can do it alone, value based care requires coordination across the entire care continuum.

That’s the reality that University of Maryland Medical System faced when they were working on their value based care efforts.  Rehospitalizations from skilled nursing facilities were hurting their value based care performance.  In order to address this challenge, University of Maryland Medical System partnered with PointClickCare to better coordinate care for patients that were discharged to a SNF.

At the HIMSS conference, Lafe Bauer, Vice President, Post-Acute Services at University of Maryland Medical System, and Robin Roberts, Director, Health IT Regulatory Affairs at PointClickCare presented a session where they shared about this experience collaborating with post-acute care to reduce hospital readmissions and benefit patients.

Below you’ll find some of the key insights and perspectives that were shared during the session along with some additional commentary.

Care for the patient requires us to often look outside the 4 walls of the hospital.  This is a great case study on how collaboration can improve the experience for patients and support your value based care efforts.

Every hospital I know is familiar with their hospital readmission numbers because it’s tied to their reimbursement.  This is true whether you’re in a value based care arrangment or not.  It was great that University of Maryland Medical System took time to know their numbers and see the impact that rehospitalizations fron skilled nursing facilities was having on their population health and value based care efforts.

One might think that 6 nurse navigators would be enough resources to be able to manage the discharges to SNFs.  However, once you break the numbers down and see that this was ~150 patients per nurse per day, you can see why 6 people alone wouldn’t be enough to address the challenge without some help from technology.

While technology is great, I love that University of Maryland Medical System also took the time to evaluate their post-acute network.  All the technology in the world can’t address a post-acute network that’s not working well.  Plus, for the technology to make the most impact, you need to know who in your post-acute network is willing to collaborate with you and leverage the technology that allows better care for the patient.

Kudos to University of Maryland Medical System for seeing that deterioration alerts wouldn’t be enough for high risk care pathways like CHF, COPD, and post-sepsis.  Plus, by partnering with PointClickCare they were able to view clinical notes for these patients and were able to start monitoring them from the start to ensure that the transition of care was seamless.  This allowed their nurse navigators to monitor these patients and intervene early if they saw any troubling indicators.  Doing so allowed University of Maryland Medical System to ensure care pathways were being followed which helped better care for the patient and avoid hospital readmissions.

A playbook is nice for a couple of reasons.  First, it ensures that best practices are being followed.  Second, I love that a playbook ensures that the acute care and post-acute care providers are on the same page.  This kind of alignment is powerful when working on collaborations like this.  Not having a playbook leads to different expectations and frustration for those involved.

Nothing better than a few examples of where this collaboration created great outcomes for both organizations and the patient.  A couple things that stand out to me in this case study.  First, the key to this collaboration working is the ability to share data between the two organizations.   This data sharing provides visibility which can lead to action.  Second, data is good, but if the two organizations weren’t ready to trust each other and work together, then all the data in the world wouldn’t have solved the problem.  That said, data plus respect and good communication between organizations leads to a really powerful result.

This second example is insightful because it highlights how the subtle things are often the most important.  However, it’s worth also pointing out that noticing this issue took great technology that shared the right information and a great nurse navigator that could filter the data to know what information mattered.  Kudos to those years of experience that allowed them to identify the issue early from all the data.

As they say, “It takes Two to Tango.”  This is particularly true when we’re talking about care transitions from acute care to post-acute care.  As we mentioned previously, all the data in the world won’t help if the two organizations don’t trust each other and are willing to collaborate to improve the outcomes for patients. However, like a great Tango dance, when you’re on the same page you can create something beautiful together.

Of course, the real question is what were the results?  Congrats to University of Maryland Medical System and their PACC SNF Network partners who saw a significant reduction in SNF readmission rates.

And I love that University of Maryland Medical System dove even deeper into the reduced CHF readmissions.  They were able to drop from an average of 24.5% readmissions to an average of 18.6% readmissions for CHF patients.

Thanks to University of Maryland Medical System and PointClickCare for sharing the detailed results of their efforts to coordinate with their network of SNFs.  I particularly loved the specific examples of patients benefitting from this effort.  It’s easy to forget that behind all these numbers are the patients who are benefitting from the work we do.

What do you think of this effort?  How have you addressed hospital readmissions from post-acute care in your organization?  What else stands out to you in this example?  Let us know your thoughts on social media.

If there’s ever been a team sport in healthcare, it’s value based care.  As much as a healthcare organization thinks they can do it alone, value based care requires coordination across the entire care continuum.

That’s the reality that University of Maryland Medical System faced when they were working on their value based care efforts.  Rehospitalizations from skilled nursing facilities were hurting their value based care performance.  In order to address this challenge, University of Maryland Medical System partnered with PointClickCare to better coordinate care for patients that were discharged to a SNF.

At the HIMSS conference, Lafe Bauer, Vice President, Post-Acute Services at University of Maryland Medical System, and Robin Roberts, Director, Health IT Regulatory Affairs at PointClickCare presented a session where they shared about this experience collaborating with post-acute care to reduce hospital readmissions and benefit patients.

Below you’ll find some of the key insights and perspectives that were shared during the session along with some additional commentary.

Care for the patient requires us to often look outside the 4 walls of the hospital.  This is a great case study on how collaboration can improve the experience for patients and support your value based care efforts.

Every hospital I know is familiar with their hospital readmission numbers because it’s tied to their reimbursement.  This is true whether you’re in a value based care arrangment or not.  It was great that University of Maryland Medical System took time to know their numbers and see the impact that rehospitalizations fron skilled nursing facilities was having on their population health and value based care efforts.

One might think that 6 nurse navigators would be enough resources to be able to manage the discharges to SNFs.  However, once you break the numbers down and see that this was ~150 patients per nurse per day, you can see why 6 people alone wouldn’t be enough to address the challenge without some help from technology.

While technology is great, I love that University of Maryland Medical System also took the time to evaluate their post-acute network.  All the technology in the world can’t address a post-acute network that’s not working well.  Plus, for the technology to make the most impact, you need to know who in your post-acute network is willing to collaborate with you and leverage the technology that allows better care for the patient.

Kudos to University of Maryland Medical System for seeing that deterioration alerts wouldn’t be enough for high risk care pathways like CHF, COPD, and post-sepsis.  Plus, by partnering with PointClickCare they were able to view clinical notes for these patients and were able to start monitoring them from the start to ensure that the transition of care was seamless.  This allowed their nurse navigators to monitor these patients and intervene early if they saw any troubling indicators.  Doing so allowed University of Maryland Medical System to ensure care pathways were being followed which helped better care for the patient and avoid hospital readmissions.

A playbook is nice for a couple of reasons.  First, it ensures that best practices are being followed.  Second, I love that a playbook ensures that the acute care and post-acute care providers are on the same page.  This kind of alignment is powerful when working on collaborations like this.  Not having a playbook leads to different expectations and frustration for those involved.

Nothing better than a few examples of where this collaboration created great outcomes for both organizations and the patient.  A couple things that stand out to me in this case study.  First, the key to this collaboration working is the ability to share data between the two organizations.   This data sharing provides visibility which can lead to action.  Second, data is good, but if the two organizations weren’t ready to trust each other and work together, then all the data in the world wouldn’t have solved the problem.  That said, data plus respect and good communication between organizations leads to a really powerful result.

This second example is insightful because it highlights how the subtle things are often the most important.  However, it’s worth also pointing out that noticing this issue took great technology that shared the right information and a great nurse navigator that could filter the data to know what information mattered.  Kudos to those years of experience that allowed them to identify the issue early from all the data.

As they say, “It takes Two to Tango.”  This is particularly true when we’re talking about care transitions from acute care to post-acute care.  As we mentioned previously, all the data in the world won’t help if the two organizations don’t trust each other and are willing to collaborate to improve the outcomes for patients. However, like a great Tango dance, when you’re on the same page you can create something beautiful together.

Of course, the real question is what were the results?  Congrats to University of Maryland Medical System and their PACC SNF Network partners who saw a significant reduction in SNF readmission rates.

And I love that University of Maryland Medical System dove even deeper into the reduced CHF readmissions.  They were able to drop from an average of 24.5% readmissions to an average of 18.6% readmissions for CHF patients.

Thanks to University of Maryland Medical System and PointClickCare for sharing the detailed results of their efforts to coordinate with their network of SNFs.  I particularly loved the specific examples of patients benefitting from this effort.  It’s easy to forget that behind all these numbers are the patients who are benefitting from the work we do.

What do you think of this effort?  How have you addressed hospital readmissions from post-acute care in your organization?  What else stands out to you in this example?  Let us know your thoughts on social media.