December 16, 2019

A Clinical Collaboration for Better Care

The entrance to the Rosewood Nursing Home & Rehabilitation Center feels more like a hotel than a health care center. Sun streams through the vaulted windows onto the richly patterned carpet, dotted with soft couches and armchairs. Families relax together in the sitting areas, chatting, admiring a large aquarium teeming with tropical fish. A small gift shop sells notecards and pretty trinkets while the receptionist welcomes visitors and guides them to their destination. A sunny dining room down the hall has tables set with tablecloths and small vases of flowers.

“We don’t call anyone here a ‘patient,’ we prefer ‘resident’ or ‘guest,’ says Larissa Lucas, MD, one of the medical directors for Rosewood. “We don’t want them to feel like this is a hospital.”

It’s only after an elderly man rolls by on a gurney that I’m reminded that this is a health care facility.

The Care Continuum

Skilled nursing facilities (SNFs), often called nursing homes, are residential facilities that provides 24-hour medical care on site. People who are cared for at SNFs are usually unable to care for themselves at home because of physical or cognitive reasons—for conditions like advanced dementia or Parkinson’s syndrome. Others are there for short term, acute stays for things like pneumonia or recovery from a surgery or a stroke.

As hospitals have become more expensive, they have relied heavily on SNFs. Ideally, a patient should move along a continuum of care from the most intensive to the least intensive health care setting. In the past, if someone went in for heart failure or major surgery they might have stayed in the hospital for up to two weeks. After being discharged, they would be moved to a skilled nursing facility for rehabilitation.

But many factors of the modern health care system have streamlined those care pathways. Health care organizations have had to re-think how they manage transitions through the system. Now, for common procedures like knee replacements, patients are sent straight to their home. With the advent of virtual check-ins, advanced home-visits, and the rising costs of in-patient stays, a patient’s follow-up care after an acute event looks very different than it used to.

“It’s great that we have all this new technology that makes it possible for patients to go home after surgery or an illness,” says Dr. Lucas. “But that means, on average, we’re getting much sicker patients placed in SNFs.”

Now, she explains, SNFs are moving away from the idea of a convalescent home and moving towards the concept of extended care—an auxiliary extension of the hospital.

Optimizing Collaboration

In order to get a better handle on the changing dynamic of hospitals’ relationships with SNFs, Partners HealthCare began looking into how to better partner with these third-party care centers. The Partners Skilled Nursing Facility Collaborative is a group of 43 SNFs that have been identified by Partners as meeting specific standards for quality of care. Partners established the Collaborative in 2013 to ensure that patients who need to receive care at a SNF can confidently choose the highest possible quality of care. Partners does not own or operate all of the facilities included in the Skilled Nursing Facility Collaborative, however some are members of the Partners Spaulding Rehabilitation Network.

“The Partners SNF Collaborative is critically important to delivering stronger clinical integration and a collaborative learning environment,” says Chuck Pu, MD, Director of Care Transition and Continuum at Partners Population Health. “It has proven its effectiveness through better outcomes at lower cost.”

Local Innovation

Rosewood is part of both the Partners SNF Collaborative as well as a smaller, sub-Collaborative of seven SNFs connected specifically to North Shore Medical Center (a member of Partners). Dr. Lucas is part of the North Shore Physicians Group Extended Care team, which, in concept, started in the late 1990’s to reform the way nursing homes are covered. Currently, the Extended Care team integrates with facilities by staffing physician-medical directors and nurse practitioners who develop more connected relationships and standardized protocol to ensure quality.

Dr. Lucas explains how unusual this is in the world of skilled nursing, but that the model is growing nationally. “Because we are Partners clinicians, we are able to communicate, document, and align with the high-quality standards throughout the transitions of care from hospital to SNF to home,” she says.

The North Shore Extended Care team also has two nurse practitioners dedicated to home visits for high risk patients discharged from the hospital or from a SNF to their homes who might not be able to make it into the PCP office—a key for improving both care transitions as well as patients’ quality of life.

“It’s a wonderful model and really different than my earlier experiences,” she says. “I never felt like I was part of those homes; but this, I really feel like I’m part of the team, which is critical.”

Quality Control

One of the things that makes the North Shore SNF Collaborative unique is that their relationship allows them to dock into the Partners electronic health record system. This means that information about patients’ medical history, their current health status, and ongoing care plan are seamlessly integrated and up to date. Sheela Kaithamattam, a Nurse Practitioner at Rosewood, explains the benefits of having an integrated electronic health system.

“Epic makes it much easier to communicate. We also get patients from other health systems [at Rosewood] and we try to get connected everywhere but it’s not consistent, not like you would think,” says Kaithamattam. “Communication is the main key for all we do; we can do so much more by being connected to [the electronic health system].”

This digital connection also enables the North-Shore SNFs to pinpoint problem areas in real-time, allowing them to make changes much more rapidly. For instance, if they see too many patients are staying beyond their recommended length of stay, they can pin-point why that is and address it.

“In the past [*and for patients outside the Partners system] we had to rely on claims-based data which is incredibly lagged. You’re receiving reports months or even a year later and it makes it hard to make impactful changes in real-time,” says Dr. Lucas. “Connecting to the electronic health record has made us much more nimble and is really helpful in shaping quality improvement initiatives.”

Smooth Transitions

Another benefit of choosing a SNF within the Partners Collaborative is the transitional care management program. Using a decision support tool integrated into the electronic health record, staff members called Transitional Care Managers can predict the ideal post-acute care setting for their patients. This is helpful in identifying appropriate patients—for example, re-routing patients who are better candidates for home-care rather than a SNF.

The tool also provides an expected length of stay, anticipated therapy needs, estimated functional improvement, and readmission risk for the patient. The SNF care team uses this data to create personalized, patient-centered care plans for patients who are part of the Partners Medicare Accountable Care Organization (ACO) or use a Medicare Advantage plan.

“Being in the role of Transitional Care Manager allows me to collaborate with the patient as well as the various branches of the care team (acute, SNF, community providers and home care) in order to provide a coordinated approach to the care of the patients in our ACO program,” says Tara Porter, the Transitional Care Manager at Rosewood.

Embracing a New Model

As the elderly population rises at an unprecedented rate and hospitals look for better, more cost-effective ways of providing care, skilled nursing facilities will only become more important. The Partners SNF Collaborative provides a cooperative framework for teamwork, innovation, and sharing lessons learned. Not only does the Collaborative improve care at SNFs, it allows clinicians to have a better picture of patients’ needs. This means understanding a patient’s social needs at home, being better linked to home care services after discharge, and being better connected to the patient’s primary care provider for follow up. By creating a seamless, holistic care environment, SNFs are reimagining what quality, patient-centered care means.

“At my previous job it was all about quantitative care; it was all about the numbers,” says Kaithamattam. “But here, it’s so much more about the quality of care you give to the patient. It really helps me have more time to be with the patient, listen to the patient, and give treatment to them accordingly. I love it.”


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