1. Partnerships & Care Transitions
Colleen Swartz, DNP, MBA, RN, NEA-BC
Penny Gilbert, MSN, MBA, RN, NE-BC, CPHQ
June 22, :30 PM

2. Partnerships & care transitions
Objectives
Provide an overview of UK HealthCare
Discuss the need for post-acute care partnerships
Review data
Discuss hurdles
Identify lessons learned

3. UK HealthCare

4. Partnerships & care transitions
Who we are:
Central and Eastern Kentucky’s only Level 1 trauma center
Receive the most severe traumas
The only Level IV neonatal intensive care unit in the area
Discharge ~105 patients/day
Some days discharge greater than 170

5. Partnerships: Why We Need Them

6. Partnerships & care transitions
Health systems recognize they cannot go it alone and are partnering with post-acute providers to achieve higher quality and lower costs. 
American Hospital Association
November 2010
Maximizing the Value of Post-acute Care
Today, patients often require a diverse array of services to treat major health episodes, manage chronic disease and pursue independent, healthy living.

7. Partnerships & care transitions
“Nationally, 1 out of 5 patients in traditional Medicare who leave the hospital go straight to a skilled-nursing facility…hospitals want more influence over where patients go and what happens while they are there”.1
1. Evans, M. (2015). Hospitals select preferred SNFs to improve post-acute outcomes. Journal of Modern Healthcare

8. Partnerships & care transitions
Eight (8) Skilled Nursing Facility Enterprises
Four (4) Home Care Agencies
Three (3) Long-Term Acute Care Facilities
One (1) Inpatient Acute Rehabilitation organization
One (1) Inpatient Substance Use Disorder Facility
One (1) Community-based Care Transitions Program (CCTP)
State Quality Improvement Organization (QIO)

9. Data: Driving Decisions

10. Partnerships & care transitions
WHERE TO START?
Data
Opportunity days
Length-of-stay
Readmissions
Bundle-payments

11. Partnerships & care transitions
Opportunity Days
Initial evaluation revealed higher opportunity days for SNFs and IRUs. So partnership developed began with those entities
SNF discharges 714 (‘16) compared to 980 (‘17 to date) CMI 2.17 (‘16) compared with (‘17)

12. Partnerships & care transitions
Length-of-Stay
1.10
1.03
1.02
Length of stay was also longer for those going to SNFs or IRUs. A process was developed to assist in a more rapid acceptance and transition for these patients. March and April O/E returned to normal at 1.02 and 1.03 respectively
Mar
Apr
Spike in numbers are driven by discharges with long hospitalizations

13. Partnerships & care transitions
Readmissions
Readmissions were climbing even for those going home—one theory was patients were going home due to inability to achieve SNF or IRF admission—then bouncing back for a readmission

14. Partnerships & care transitions
October 2017
Bundled Payments
Cardiac
Patients DC locations
home
home care
Skilled nursing
Inpatient rehab unit
Substance use disorder rehab unit
Partnerships will be key 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 30

15. Hurdles: Down the Rabbit Hole

16. Partnerships & care transitions
Hurdles develop out of the unexpected or unforeseen. It will be important to work through those from all perspectives, not only the acute care side. Things are very different from a post-acute care perspective.

17. Partnerships & care transitions
HURDLES
Expectations v. realities
Communication
Outcomes
Difference of opinions

18. Lessons Learned

19. Partnerships & care transitions
Lessons Learned
Important your partners know what you need from them and why
Be ready to make compromises
Use the data to drive expectations
Use data to drive executive support
Stay focused on overall strategy
You really can climb out

20. Partnerships & care transitions
Summary
University of Kentucky HealthCare® central & eastern KY only Level I trauma facility
Often discharge and admit ~105 patients per day
Post-acute care partnerships are no longer a luxury but a necessity
Decisions/expectations should be data driven
Everyone must share & communicate
Partnership hurdles will come and go
Focus on your overall strategy
Move on when necessary

21. Partnerships & Care Transitions Colleen Swartz, DNP, MBA, RN, NEA-BC Penny Gilbert, MSN, MBA, RN, NE-BC, CPHQ June 22, :30 PM

22. Partnerships & care transitions
Questions