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Accountable Care Strategies to Improve Hospital-SNF Care Transitions
Accountable Care Strategies to Improve Hospital-SNF Care Transitions
Accountable Care Strategies to Improve Hospital-SNF Care Transitions
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In the future, skilled nursing facilities (SNF) readmission rates could be subject to penalties similar to those CMS has put in place for hospitals, such as when SNF readmissions to a hospital occur for certain conditions, within a particular timeframe.

To avoid this, many hospitals and health systems, including Bravo Health, Atrius Health and others are collaborating with preferred SNF providers to improve care and reduce unplanned 30-day readmissions in vulnerable populations. These partners have discovered the value of developing SNF networks as they move toward an accountable care organization (ACO) model.

Accountable Care Strategies to Improve Hospital-SNF Care Transitions provides a look at a health system-SNF network that has curbed rehospitalizations and length of stay for participants.

The crucial hospital-to-SNF transition was identified as a top priority of healthcare organizations during a 2013 HIN survey of executives on care transition management.

In this 25-page resource, Summa Health System shares how it rallied 40 independent skilled nursing facilities (SNF) to form a network that has elevated its hospital-to-SNF transfers of care, reducing readmissions and length of stay for Summa patients released to SNFs in the process.

Industry thought leaders advise hospitals to monitor what goes on across its care continuum and to partner with facilities it discharges to most often to reduce 30-day readmissions. Summa Health System has done just that with the development of its Care Coordination Network, a community partnership with SNFs, that is reducing hospital readmission rates and average length of stay for patients transferred to these SNFs.

Accountable Care Strategies to Improve Hospital-SNF Care Transitions presents this case study in reducing SNF-to-hospital readmissions. Carolyn Holder, manager of transitional care for Summa Health System and Michael Demagall, administrator of Bath Manor & Windsong Care Center, two SNFs participating in the network, describe the key elements of the partnership:

  • Three key areas that improved care transitions between Summa's hospitals and SNFs in its community;
  • Strategies implemented by Summa to address the key hospital-to-SNF transition challenges;
  • Steps in developing a QI process that monitors transitions to identify weaknesses in the care transition process; and
  • Development and enhancement of the partnership as the hospital system works toward development of an ACO.

Table of Contents

  • Case Study: SNF Care Coordination Network Reduces SNF-Hospital Readmissions
    • Developing a Care Coordination Network
    • Decision to Developing a Care Coordination Network
    • Staffing and Implementing a Care Coordination Network
    • What Does the Care Coordination Network Accomplish?
    • Barriers to Patient Care
    • Formulating Solutions to Barriers
    • Transfer Form for Post-Acute to the ED
    • Measuring Outcomes Between Facilities
    • Calculating Readmission Rate
    • Formation and Development of an ACO
  • Q&A: Ask the Experts
      Sharing Information between SNF and Hospital
    • Physician Interaction with Patients in SNFs
    • Sharing Preferred Provider Information with Patients
    • Giving Patients a Provider Choice
    • SNF Specializations
    • CHF Transition Protocol
    • Future Program Enhancements
  • Glossary
  • For More Information
  • About the Speakers
Publication Date: September 2013
Number of Pages: 25
ISBN 10: 1-939167-67-1 (Print version); 1-939167-68-X (PDF version)
ISBN 13: 978-1-939167-67-5 (Print version); 978-1-939167-68-2 (PDF version)
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