Based on promising outcomes in patient care and satisfaction, two nursing homes – Centers Health Care and Providence Rest – will expand their BPHC pilots for another six-month period.
The pilots seek to reduce the rates of re-hospitalizations, transitions and unnecessary emergency room visits while ensuring that patients and their families are satisfied with their care.
Centers Health Care utilizes its referral management platform to coordinate post-discharge community-based care. Providence Rest uses telehealth to assess patients during hours when a physician is not on site.
“We are encouraged by our results in the first six-month pilot periods and look forward to continuing to evaluate their progress and look at opportunities for enhancements,” says Dr. J. Robin Moon, Senior Director, System Integration.
Centers Health Care developed its “Community-Based Referral Pilot” to ensure that recently-discharged patients with high-risk diseases are connected to quality, coordinated care with primary care physicians, specialists and other community services. Centers Health Care’s referral management platform, CentersLink, coordinates patients’ care once they are discharged from the nursing home.
CentersLink care coordinators speak with patients daily to check in and determine if additional care and services may be needed – whether it’s a visit to a primary care physician, the need for homecare or transportation to a doctor’s office. They schedule appointments, follow up on visits and communicate with doctors and other community providers on the patient’s care.
Preliminary findings during the pilot period show significant savings in care costs with 71% of enrolled patients attributing CentersLink daily calls to care improvements and 85% saying they would continue the services post-pilot.
Currently, those enrolled in the pilot have diagnoses that include HIV/AIDS, cardiovascular disease, renal failure and/or wound care. As the pilot continues, it will include all patients with Type 2 diabetes and others identified as being at high risk for re-hospitalization.
Providence Rest partners with StationMD, a telemedicine company, to assess patients’ urgent health needs during evening and weekend hours when a physician is not on the premises. When a patient experiences symptoms indicating a need for urgent or emergency care, the nursing staff contacts StationMD.
Through secure video conference application, a Station MD emergency physician joins the nurse and resident at bedside to assess the patient’s condition and next steps. Family members can be conferenced into the consultation as well. If the decision is made to transfer the resident to a hospital, StationMD contacts the ER and shares patient health information so that the resident can be moved through the process more smoothly. Hospitalization rates decreased from 12% to 6% during the six-month pilot.
Planning for the Nursing Home Pilots initiative began in summer 2017 when representatives from post-acute facilities in our PPS convened at BPHC to share their insights, experiences and challenges with providing and coordinating care for patients who often have complex needs.
Areas identified to address included transitioning patient care (e.g., from hospital to nursing home to community), strengthening provider collaboration, and utilizing technology to share patient medical information and access local resources.
For more information, contact J. Robin Moon.