Improving Morbidity During Post-Acute Care Transitions for Sepsis

2019 ◽  
Author(s):  
Keyword(s):  
Acute Care ◽  
Care Transitions ◽  
Post Acute Care

Abstract WP356: Unbundling Care Transitions and Cost After Stroke: Results From the BPCI-Advanced Program

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Geri Sanfillippo ◽  
Brian Olkowski ◽  
Hermann Christian Schumacher ◽  
David Dafilou ◽  
Colleen Bowski ◽  
...  
Keyword(s):  
Acute Care ◽  
Resource Utilization ◽  
Care Coordination ◽  
Program Implementation ◽  
Care Transitions ◽  
Inpatient Rehabilitation ◽  
Hospital Length Of Stay ◽  
Early Supported Discharge ◽  
The Impact ◽  
Post Acute Care

Introduction: The Centers for Medicare and Medicaid Services bundled payment for care improvement advanced (BPCI-A) program incentivizes providers to better coordinate care, reduce expenses, and improve quality. The purpose of this study was to determine the impact of improving post-acute care coordination after stroke on quality and resource utilization in the BPCI-A program. Methods: Capital Health collaborated with post-acute providers to improve communication, identify criteria for early supported discharge to the community, expedite home health and outpatient services, reduce readmissions, and initiate advanced care planning. The redesigned post-acute care coordination program was implemented at Capital Health’s primary and comprehensive stroke center. Quality outcomes and resource utilization measures for patients enrolled in the BCPI-A program were compared to BPCI-A eligible patients prior to program implementation. Results: Forty-three patients enrolled in the BCPI-A program were compared to 77 patients eligible for enrollment. Clinical and demographic characteristics were similar (p>.05). After program implementation, 21.5% fewer patients were discharged to an inpatient rehabilitation facility (p=.024) and 14% more patients were discharged to inpatient hospice (p<.001). On average, post-acute cost decreased $16,608 per patient (p=.007) resulting in a $16,820 reduction in the 90-day cost per episode (p=.011). The 90-day hospital readmission rate decreased insignificantly by 14.1% from 23.4% to 9.3% (p=.056). Hospital cost, hospital length of stay and the 90-day mortality rate were unchanged (p>.05). Conclusion: The coordination of post-acute services facilitates care transitions after stroke. The identification of patients meeting criteria for early supported discharge to the community or admission to inpatient hospice helped reduce post-acute cost without increasing 90-day readmission or mortality.

scholarly journals Electronic Information Sharing to Improve Post-Acute Care Transitions

2018 ◽  
Vol 2018 (1) ◽  
pp. 17468
Author(s):  
Dori Amelie Cross ◽  
Julia Adler-Milstein ◽  
Jane Banaszak-Holl ◽  
Jeffrey Scott McCullough
Keyword(s):  
Information Sharing ◽  
Acute Care ◽  
Care Transitions ◽  
Electronic Information ◽  
Electronic Information Sharing ◽  
Post Acute Care

scholarly journals ECHO-CT: An Interdisciplinary Videoconference Model for Identifying Potential Postdischarge Transition-of-Care Events

2021 ◽  
Vol 16 (2) ◽  
pp. 93-96
Author(s):  
Mariana R Gonzalez ◽  
Lauren Junge-Maughan ◽  
Lewis A Lipsitz ◽  
Amber Moore
Keyword(s):  
Acute Care ◽  
Care Transitions ◽  
Transition Of Care ◽  
Nursing Facilities ◽  
Skilled Nursing ◽  
Surgical Services ◽  
Care Facilities ◽  
Acute Care Facilities ◽  
Post Acute Care

BACKGROUND: Discharge from the hospital to a post–acute care setting can be complex and potentially dangerous, with opportunities for errors and lapses in communication between providers. Data collected through the Extension for Community Health Outcomes–Care Transitions (ECHO-CT) model were used to identify and classify transition-of-care events (TCEs). METHODS: The ECHO-CT model employs multidisciplinary videoconferences between a hospital-based team and providers in post–acute care settings; during these conferences, concerns regarding the patient’s care transition were identified and recorded. The videoconferences took place from January 2016 to October 2018 and included patients discharged from inpatient medical and surgical services to a total of eight participating post–acute care facilities (skilled nursing facilities or long-term acute care hospitals). RESULTS: During the interdisciplinary videoconferences in this period, 675 patients were discussed. A total of 139 TCEs were identified; 58 (41.7%) involved discharge communication or coordination errors and 52 (37.4%) were classified as medication issues. CONCLUSION: The TCEs identified in this study highlight areas in which providers can work to reduce issues arising during the course of discharge to post–acute care facilities. Standardized processes to identify, record, and report TCEs are necessary to provide high-quality, safe care for patients as they move across care settings.

scholarly journals Accountable Care Organizations and Post-Acute Care: A Focus on Preferred SNF Networks

2018 ◽  
Vol 77 (4) ◽  
pp. 312-323 ◽  
Author(s):  
Gregory Kennedy ◽  
Valerie A. Lewis ◽  
Souma Kundu ◽  
Julien Mousqués ◽  
Carrie H. Colla
Keyword(s):  
Survey Data ◽  
Acute Care ◽  
Care Transitions ◽  
Accountable Care Organizations ◽  
Nursing Facilities ◽  
Accountable Care ◽  
Mixed Methods Design ◽  
Structured Interviews ◽  
Skilled Nursing ◽  
Post Acute Care

Due to high magnitude and variation in spending on post-acute care, accountable care organizations (ACOs) are focusing on transforming management of hospital discharge through relationships with preferred skilled nursing facilities (SNFs). Using a mixed-methods design, we examined survey data from 366 respondents to the National Survey of ACOs along with 16 semi-structured interviews with ACOs who performed well on cost and quality measures. Survey data revealed that over half of ACOs had no formal relationship with SNFs; however, the majority of ACO interviewees had formed preferred SNF networks. Common elements of networks included a comprehensive focus on care transitions beginning at hospital admission, embedded ACO staff across settings, solutions to support information sharing, and jointly established care protocols. Misaligned incentives, unclear regulations, and a lack of integrated health records remained challenges, yet preferred networks are beginning to transform the ACO post-acute care landscape.

scholarly journals A Framework for Supporting Post-acute Care Transitions of Older Patients With Hip Fracture

2019 ◽  
Vol 20 (4) ◽  
pp. 414-419.e1 ◽  
Author(s):  
Paul Stolee ◽  
Jacobi Elliott ◽  
Kerry Byrne ◽  
Joanie Sims-Gould ◽  
Catherine Tong ◽  
...  
Keyword(s):  
Hip Fracture ◽  
Acute Care ◽  
Older Patients ◽  
Care Transitions ◽  
Post Acute Care

scholarly journals What’s Driving SNF Readmission Rates? Exploring Differences in Processes Between High and Low Performing Hospitals

2020 ◽  
Vol 4 (Supplement_1) ◽  
pp. 40-40
Author(s):  
Kirstin Manges ◽  
Roman Ayele ◽  
Marcie Lee ◽  
Chelsea Leonard ◽  
Emily Galenbeck ◽  
...  
Keyword(s):  
Older Adults ◽  
Best Practices ◽  
Acute Care ◽  
Transitional Care ◽  
Care Transitions ◽  
Ethnographic Study ◽  
Nursing Facilities ◽  
Readmission Rates ◽  
Care Processes ◽  
Post Acute Care

Abstract Despite the increasing national focus on improving post-acute care outcomes, best practices for reducing readmissions from skilled nursing facilities (SNFs) are unclear. The objective of this rapid ethnographic study was to observe processes used to prepare older patients for post-acute care in SNFs, and to explore differences between hospital-SNF pairs with high or low thirty-day readmission rates. We stratified hospitals according to readmission rates from SNF and used convenience sampling to identify two high and two low performing sites and associated SNFs (n=5). We conducted intensive multi-day observations (n=148 hours) and key informant interviews (n=30 clinicians) to describe hospital processes for discharging patients to SNF. We used thematic analysis of interviews and fieldnotes to identify differences in transitional care processes of hospitals discharging patients to SNFs. Hospitals used five major processes prior to SNF discharge that could affect care transitions for older adults: recognizing the need for post-acute care, deciding level of care, selecting SNF facility, negotiating patient fit, and coordinating care with SNF. During each stage, high-performing sites differed from low-performing sites by focusing on: 1) earlier, ongoing, systematic identification of high-risk patients; 2) discussing the decision to go to a SNF as an iterative team-based process; and 3) anticipating barriers with knowledge of transitional and SNF care processes. Identifying variations in processes used to prepare patients for SNF provides critical insight into the best-practices for transitioning patients to SNFs and areas to target for improving care of older adults.

scholarly journals And Now Post-Post-Acute Care Transitions

2016 ◽  
Vol 31 (12) ◽  
pp. 1410-1411
Author(s):  
Stephen F. Jencks ◽  
Joanne Lynn
Keyword(s):  
Acute Care ◽  
Care Transitions ◽  
Post Acute Care

Abstract TMP43: Therapy Time, Settings and Transitions Across All Post-Acute Care (PAC) Settings in the First Year After Stroke in Medicare Patients

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
James F Burke ◽  
Crystal Feng ◽  
Lesli E Skolarus
Keyword(s):  
Acute Care ◽  
Speech Therapy ◽  
Care Transitions ◽  
Inpatient Rehabilitation ◽  
Stroke Survivor ◽  
Median Number ◽  
First Year ◽  
Hospital Inpatient ◽  
Fee For Service ◽  
Post Acute Care

Introduction: Post-acute care (PAC) may be an important factor in recovery, yet little is known about stroke patients’ receipt of PAC across settings. To optimize future PAC, we described all settings in which stroke survivors receive therapy, the total time receiving therapy in each setting and transitions between settings. Methods: All Medicare fee-for-service patients admitted in 2011 and discharged alive with a primary diagnosis of acute ischemic stroke or intracerebral hemorrhage (ICD-9-CM 431, 433.x1, 434.x1, 436) were identified from the Medicare Inpatient file. Medicare Standard Analytic Files were used to identify therapy in all PAC settings — hospital, Inpatient Rehabilitation Facilities (IRF), Skilled Nursing Facilities (SNF), Home Health (HH) and Outpatient for 12 months after the index stroke admission. Physical (PT), occupational (OT) and speech therapy (SLP) were identified using CPT and revenue codes. For each therapy modality, minutes of therapy was estimated by cross-walking Medicare billing codes to the American Medical Association’s average intra-service time for each code. We then estimated time in each therapy modality, total therapy time in each PAC setting and the number of transitions between settings. Results: Our cohort included 186,168 patients, 59% female with a mean age of 80.1 (SD 8.2). 86%, 78% and 74% received any PT, OT or SLP. For patients who received a specific therapy modality, the median therapy minutes was: 762 PT, 661 OT, and 684 SLP. Of all patients, 22% received PT in an IRF, 38% in a SNF, 23% in HH and 36%. For patients who received PT in a given setting, the median number of minutes per setting was: 86 hospital, 747 IRF, 718, 446 HH, and 553 outpatient. Slightly smaller proportions received OT and SLP for slightly shorter times across settings. Multiple care transitions were common. Of all patients, 75% had more than 1 transition, 45% have 3+, 25% have 5+, 14% have 7+ and 6% have 9+ in the 12 months following stroke. Conclusions: During the first year following their stroke, the median stroke survivor who receive therapy spends 35 hours in therapy and has 3 transitions between settings. Most therapy is delivered outside of the hospital and settings transitions are common raising concerns for care fragmentation.

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