Care transitions have the potential to present many problems for patients. Whether the transfer is to a hospital from the patient’s residential setting, or from the hospital to post-acute care or back home, it is common for transitions to be rushed, with no specific person identified as “in charge” of the transfer, little standardization of shared information, patient and family confusion and other potential challenges. WHA’s Post-Acute Care Work Group, at its June 16 meeting, heard from two speakers about how their health systems are implementing methods to make care transitions more successful for the patient and caregivers, resulting in higher quality care and better patient outcomes.
Maria Brenny-Fitzpatrick, director of care transitions for UW Health, described several initiatives that have led to better care transitions into and out of UW Hospital in Madison. These initiatives include creating post-acute provider coalitions; standardizing the sharing of essential transfer information; creating post-acute preferred provider networks; and a joint effort by three Dane County hospitals to establish the same quality metrics they request from area skilled nursing facilities.
Becki Detaege, team leader, transition of care support services at Bellin Health in Green Bay, described Bellin’s post-acute care planning as one of the 19 Next Generation Accountable Care Organizations (Next Gen ACO) in the U.S. Next Gen ACOs benefit from enhancements that improve post-acute care planning and coordination, including a waiver of the three-day inpatient hospital stay requirement for SNF admission, payment for post-discharge home visits and waivers that allow for expansion of telehealth services. Bellin utilizes multiple strategies to improve post-acute care, including establishment of preferred partnerships with PAC providers; proactive care management; use of technology to support care coordination across the continuum; standardized protocols, care pathways, and workflows; and strengthening the advanced care planning process.
Work Group members then shared their ideas about transitions of care in their own facilities. Members agreed that a widespread dissemination of best practices would be invaluable as post-acute care becomes an increasingly important consideration for hospitals and health systems across the state.
The Work Group will meet again later this summer to begin formulating its final recommendations.