Locating and maintaining stable postacute care settings for patients in order to prevent hospital readmissions was the focus of the WHA Post-Acute Work Group’s Nov. 22 meeting. Elaine Makarowski, advanced practice nurse practitioner and clinical supervisor of UW Health’s Advanced Practice Provider Long-Term Care Team, met with the work group and described the team’s work. The team has 14 nurse practitioners (NPs) and 5 RN skilled nursing facility (SNF) case managers who cover about 650 patients at 18 SNFs in Dane County. The team covers all UW/Unity Point Health - Meriter primary care providers with patients in Dane County.
The idea to follow discharged hospital patients at post-acute care settings was first implemented at UW Health 20 years ago. At that time, one nurse practitioner saw SNF patients for just a few doctors. As the acuity of patients increased, UW Ambulatory Operations and Population Health recognized the need to add more NPs to cover patients for all primary care providers. The department was centralized within UW Health in 2016 and patients of all Unity Point-Meriter primary care providers were added to the caseload.
The team works to decrease hospital readmissions and ensure smooth discharge transitions by collaborating with nurse case managers in SNFs. This collaboration helps ensure the patient’s care needs are met. The program has documented a decrease in hospital readmission rates due to the program. The NPs are very familiar with the patients and their families. Because of the rapport with the SNF leadership and staff, facility staff can direct all calls to the NPs, eliminating a large percentage of calls to primary care providers and increasing the primary provider’s productivity in the clinic.
The work group discussed how similar models have been implemented in other Wisconsin hospitals and health systems and identified which changes in federal SNF regulations could be beneficial to the smooth operation of these programs. Other topics the work group discussed were Aging and Disability Resource Center delays in completing functional screens for Family Care eligibility, resulting in unnecessary lengths of stay in nursing homes; post-acute needs of complex patients; and WHA advocacy activities that facilitate post-acute care planning.
The work group will meet again in January. For further information, contact WHA Vice President of Policy Development Laura Rose