1. Kathy Clodfelter, MSN, MBA, RN, NE-BC
Shelly Evans, B.S.

2. BACKGROUND
Our Story Begins
With SWIONE

3. 2014 SWIONE Presentation by Memorial Hospital and Health Care Center Nurse Practitioner Roles in Community Health

4. It’s all about relationships….
Partnership with 6-area Skilled Nursing Facilities (SNF) and their staff
Relationship building with patients, families, and significant others
Relationship building with SNF Medical Directors

5. Trends MHHCC experienced
Earlier intervention of chronic illness issues
Staff education opportunities
Interaction with family members increased trust and confidence in level of care
Rapport and support from Medical Directors

6. Why and How We Got to Where We are Today
Shelly Evans

7. Healthcare Reform / Accountable Care Organizations (ACO’s)
High post-acute spend and readmission rates
Lack of continuity of care
High emergency department utilization
Patient transition issues – no coordination
Patient / family dissatisfaction
High cost of care

8. Next Generation ACO – 2016
Assumed risk for readmission rates, Medicare spend for our ACO population
Strategic Initiatives to improve patient care while lowering readmissions and Medicare costs
NP model created to drive desired outcomes – Triple Aim
Improving patient care & quality
Improving patient & family experience
Reducing LOS, readmission rates & Medicare spend
Deliver the right care at the right time at the right place

9. Challenges / Gaps Documentation
Patient orders (therapy, diet, medications)
Dialysis treatments
Transitions in care
Patient resources
Quality data reporting
Emergency Department
Palliative care – early interventions
Technology / EMR
SNF staff coordination / education
Medication gaps
Transportation issues
Discharge summaries
Therapy department coordination
Acute – Post Acute care coordination

10. Skilled Nursing Facility (SNF) Networks
POST ACUTE NP PROGRAM
Skilled Nursing Facility (SNF) Networks
Partner Facilities (Embedded NP model)
11 SNF’s / 5 Nurse Practitioners
Developed parameters for SNF selection (Star rating, quality metrics, rates)
Call center – enhanced NH triage service (clinical protocols)
Development of facility fees – subsidize NP costs
NP’s bill for patient visits
Collaborating physician / Medical Director
Preferred Provider facilities (3-day SNF waivers)
24 SNF’s / local & regional facilities
3 day SNF waiver benefit – ACO patients
Deaconess, Memorial Hospital, Good Sam, GGH, Ferrell, Methodist
CMS requirements – overall star rating of >3

11. Post Acute NP program Program Enhancement NP Nursing home visits
Admission, acute, discharge, regulatory visits
NP Services agreement – admitting physicians
Quality Metrics – track 22 metrics monthly
Monthly meetings – SNF administrator, admissions, social work, therapy department, discharge planners
Discuss all readmissions and why they occurred
NP education for SNF staff
Infection prevention, wound care, what to look for
SNF discharge planning coordination– transition to home
Enhanced communication and hand off processes streamlined

14. All Facilities Combined

15. Skilled Nursing: Embedded NP Initiative Measuring Success
____________________________________________________
Baseline Data FY15 vs FY18
(All Deaconess Patients)
30-day Readmission rates: 26.9% to 11.0%
Average Length of stay (short term, rehab to home patients): 36 days to days
Provider Visits within 2-business days of SNF admission: 12% to 91.8%

16. All Facilities Combined

17. All Facilities Combined

18. SNF Partner

19. Current Initiatives Progress
SNF Waiver programs
Anthem / Humana Floor to SNF, ED Intercept
3-day SNF waiver program
465 waivers / 1163 IP days saved
Utilization Management
Meds to Beds Program
↓LOS 5+ days – SNF therapy department collaboration
↓RA rates ↑patient care & satisfaction
Post Acute Services
In – Network Utilization
Improved handoff processes
COPD / CHF Education – SNF’s
Risk Stratification Tool, D/C summaries, Deaconess Care Link
Acute readmission teams
Case management collaboration

20. Future State - Initiatives
NP program expansion
9 NP’s, 20 SNF’s
NP on-call
Telehealth Solutions
Waivers
Post Discharge waiver
Anthem / Humana waiver program expansion
Advanced Directives Project
24 hour RN triage (call center)
Post acute case manager model
Community organization collaboration
Readmission projects
Acute nurse managers
SNF Education program

22. Contact Information Kathy Clodfelter, MSN, MBA, RN, NEM-C DVNA, Case Management, Post Acute Services Shelly Evans, B.S., Post Acute Services