Skilled nursing partnership shrinks readmissions

Portrait of Dave UnderrinerMahnaz Ahmad, M.D.
Medical director, Providence Geriatric and Long-Term Care Team

Oct. 16, 2013

Providence Medical Group in Oregon is beginning to see the results of a new model of care for patients transitioning from hospitals to skilled nursing facilities, or SNFs. The geriatric and long-term care team was created at the end of 2010 and launched the following year. Until then, PMG had no systematic approach to referring patients to SNFs. This led to patients being referred to facilities in the Portland metro area with which PMG had no established, coordinated relationship.

The program already is reaping rewards. Thirty-day readmission rates from participating facilities averaged 5.34 percent in the first half of 2013, compared to Providence’s overall readmission average of 7.21 percent for the same period.

PMG has begun working with designated SNFs selected based on their willingness to collaborate with PMG to improve patient care and the volume of PMG patients cared for at the facility. The geriatric and long-term care team rounds in the SNFs two to three days per week.

Patients are seen by a team physician, usually within 72 hours of admission. The physician conducts a comprehensive admitting history and physical; performs medication reconciliation; addresses medical issues, including polypharmacy; and talks to the patient about care goals and POLST wishes. The physician also coordinates care with other specialists and, when appropriate, provides targeted attention to specific geriatric syndromes such as dementia, depression or falls.

Continuity of care with the patient’s primary care provider is maintained through documentation in Epic. The program closes the loop by providing the primary care physician with a detailed discharge summary and a follow-up appointment for the patient within seven days. 

The geriatric and long-term care team worked to standardize practices in the chosen facilities, creating and implementing routine admission orders and a standard emergency department admission form, which equips emergency doctors with all the necessary information about a patient. The documentation in Epic also is done through standard templates. Additionally, providers have influenced the quality of care at the facilities by providing education to staff through routine in services on clinical issues common to long-term care facilities.

This program is serving as a cornerstone for a broader post-acute care strategy for the Oregon Region. The goal is to extend our care coordination by partnering with post-acute care providers (including skilled nursing facilities) to help people maintain their independence and support their health care needs outside the hospital.

These strategies aim to further the objectives of Triple Aim: to improve the patient’s experience, lower costs and improve population health for this vulnerable population.

To learn more, contact program manager Jenni Barlow.