It Takes a Village: Developing Preferred Partnerships for Post-Acute Care Nancy Maggard, MSN, RN NE-BC, RN Case Manager, Enterprise Manager Cheryl Talbert, MSW, LCSW, Social Work Enterprise Manager University of Kentucky HealthCare LEARNING OBJECTIVES
OUTCOMES
• Discuss the importance of acute care entities developing preferred postacute care partnerships. • Examine data findings and ability to implement in various organizational settings.
UKHC LOS Index 1.15 1.10 1.05
PROBLEM
1.00
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• As healthcare needs continue to increase in complexity (medical and social) multiple layers of resources are required to safely transition patients to the appropriate level of care. Healthcare organizations must successfully navigate through internal and external forces and encourage collaboration among multidisciplinary teams and community resources for successful discharge planning and partnership alignment.
0.95 0.90 0.85 0.80
Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May 2016 2017 2018 LOS Index 1.0 0.9 1.1 1.0 1.0 0.9 0.9 0.9 1.0 0.9 1.0 0.9 0.9 1.0 0.9 0.9 0.9 0.9 UKHC Readmittance Rate 11.5% 11.0% 10.5%
TARGET AUDIENCE
10.0%
• Organizations serving individuals with complex medical and social needs.
9.5%
LESSONS LEARNED
9.0% 8.5%
GOAL • The University of Kentucky HealthCare’s Preferred Partnership Program was developed to drive post-acute alliances with the aim of meeting the complex needs of patients; reducing length of stay (LOS) and decreasing readmissions.
8.0%
Dec Jan
Feb Mar Apr May Jun
Jul
Aug Sep Oct Nov Dec Jan
Feb Mar Apr May
2016 2017 2018 Vizient 30 Day Readmits 10.5% 9.5% 9.7% 10.8%10.4% 9.7% 9.6% 10.4% 9.7% 9.6% 9.9% 10.3%10.9% 9.5% 10.1%10.7% 9.3%
UKHC CMI 2.05 2.00 1.95
CHANGES IMPLEMENTED
1.90
• Annual evaluation of preferred partnerships (are patient needs being met?). • Review of challenges and barriers with preferred providers in meeting complex needs. • Established partnerships with Acute Rehabilitation providers; skilled nursing providers; home health agencies; community resources charged with addressing vulnerable populations and identifying social determinants of health. • Weekly review of patients with LOS < 20 days.
1.85 1.80
Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May 2016 2017 2018 CMI 2.0 1.9 1.9 2.0 1.9 1.9 1.9 1.9 2.0 1.9 1.9 1.9 1.9 1.9 1.9 2.0 1.9 1.9
• Continued evaluation of data • Decrease in partnerships due to organization’s inability to meet complexity of patient needs • Limited ability of partners to cover geographical service areas
WHAT WORKED WELL • • • •
Decreased LOS Maintained benchmark for readmissions Improved communications among post-acute providers Improved collaboration with multidisciplinary team and post-acute acute providers