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Care coalition chips away at transition problems


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Care coalition chips away at transition problems 

After reading this article, you will be able to:

  • Describe the benefits of a care coalition 
  • Identify transfer issues the coalition overcame

Sometimes transitioning patients to the next level of care can be a chore. There are several different types of agencies (home health, nursing homes, hospices) and several individual agencies within those types, all requiring different information to accept a referral. This can cause aggravation and, more importantly, delays.

Instead of complaining about agencies and their different requirements, three hospitals in Illinois (Memorial Hospital, Anderson Hospital, and St. Elizabeth’s Hospital) decided to create a care coalition, which would create a forum for hospitals and postacute agencies to discuss transition issues. 

Creating a coalition 

When Heather Corbitt, MSW, LSW, ACM, social service manager and director of case management at Memorial Hospital in Belleville, decided to reach out to neighboring hospitals to create a care coalition, ”it wasn’t hard to get people on board,” she says. 

Memorial Hospital was already friendly with two facilities in the area, and they were positive toward the idea. During the process, Corbitt discovered that neighboring Anderson Hospital was already meeting with representatives from area nursing homes, hospices, and home health agencies every quarter. 

“The care coalition was born out of the nursing home meetings that Anderson Hospital held,” says Nancy Vetter, MSW, LCSW, director of social services at Anderson Hospital in Maryville.

Corbitt and St. Elizabeth Hospital’s director of case management attended one of Anderson’s meetings and presented the coalition idea to the postacute providers. The group was larger than Corbitt anticipated—more than 80 people. 

“I was worried we would not be able to pinpoint certain issues with all the various agencies there (e.g., nursing homes, home health agencies, and hospices),” she says.

So the hospital representatives decided to focus on nursing home transitions first. There were several opportunities to improve transitions to that setting, given that the largest population of hospital patients transition to that setting. 

Today, more than 30 representatives from hospitals and nursing homes attend the care coalition’s semiannual meetings. The coalition formed a steering committee with representatives from three hospitals and three nursing homes that meets every six weeks to develop the agenda for the bigger meetings and work on action items. 

‘Chipping away’ at transition problems

During the care coalition’s first semiannual meeting, Corbitt asked for examples of transition areas that needed improvement. 

The following are just some of the areas the coalition has improved: 

  • Late discharges. Often physicians tell the hospital staff they will visit to discharge the patient at noon, but don’t show up until later. That can be a problem for nursing homes that will not accept transfers after 3 p.m. The coalition is working with those nursing homes to see if they can “keep their doors open later,” Corbitt says, and she adds that the majority now accept patients after 3 p.m. 
  • Referral response time. Ideally, the hospitals would like to have a referral response from nursing home facilities within an hour. To speed up the process, the coalition created a survey which asks each facility for the specific information they need to make a referral determination within that time frame. “We aren’t there yet, but we are chipping away,” says Corbitt.
  • Patient preparedness. The coalition created a nursing home guide that helps patients and their families prepare for the transition to a nursing facility. The brochure explains what to look for in a nursing facility, what services Medicare covers, and what patients should bring (e.g., legal documents, clothing), Vetter says.
  • Transportation. The state of Illinois has cut Medicaid funding for ambulance transfers, Vetter says. Some nursing homes have bought vans to transport their patients. The coalition has also invited Governor Pat Quinn to attend a meeting to discuss cuts to transportation funding. He has yet to attend, says Corbitt.
  • Observation education. Corbitt says people have come to the hospital and said, “The nursing home told us to stay here three nights so we can use Mom’s Medicare to pay for the nursing home.” This is clearly inappropriate. The coalition took the time to explain that patients must meet admission and continued stay criteria in order to qualify for a Medicare-covered stay. The coalition also held presentations on how the Recovery Audit Contractor program affects the hospital and nursing home settings, says Corbitt.

Spreading the coalition 

The care coalition has shared its program with other hospitals in the state as well as at the ACMA’s national conference, and the idea is catching on.

Representatives from two hospitals in northern Illinois sat in on a coalition meeting and have since started their own coalition, Vetter says. 

Another hospital in the state didn’t have such luck, according to Corbitt. “[Hospital staff] didn’t get as much interest from neighboring hospitals. So we encouraged them to go solo and create a coalition between themselves and nursing homes.” 

Sometimes neighboring hospitals aren’t willing to air dirty laundry, Corbitt says, but in the long run everyone benefits from joining forces. “As more than one hospital, we can make an impact for the greater good.” 

Vetter agrees and says that sharing information with neighboring hospitals has been one of the biggest benefits of the coalition.

“We can always do things better. So we work together instead of as individuals, and it’s phenomenal,” she says. “There is enough work out there for all of us. We don’t need to each try and capture all the pie. There is enough pie out there to fill everybody’s tummies.”