By Melinda Young
A health system tackled the challenges of transitioning patients to skilled nursing facilities (SNFs) through a relationship with a multisite SNF. Together, the organizations created a bed reservation program, which results in a smoother and more effective transition process.
“We created capacity in our hospital to be able to serve more patients that needed a critical level of care,” says Jenn Leitch, MN, RN, CCM, CGS, administrative director in the division of care management at Oregon Health & Science University (OHSU). “We service all of Oregon. With this program, we’ve been able to serve [more than] 2,500 patients from the beginning of the program to the end of December 2022.”
Hospitals across the United States have struggled with transition barriers because of the COVID-19 pandemic. Oregon is experiencing a significant nursing shortage across skilled health, Leitch notes. This was why case management leaders started a program that would help improve the transition process.
“As we build this relationship with [the SNF], we meet with them weekly and talk about nursing, social services, physical therapy, and we learn what’s going really well and what areas where they need support,” Leitch adds.
The result is the hospital saved about 20,000 patient days from mid-2019 through December 2022 by transitioning patients at the right time and by overcoming obstacles. “In other words, without the program, the patient would still be in the hospital bed,” Leitch says.
The program also accommodates patients’ needs, says Molly Ghassemi, BSN, a nurse manager at OHSU Hospital. “Our patients are all over Oregon and Southwest Washington, and we wanted to find [facilities] that could support patients in those different localities,” Ghassemi says.
It worked well to form a relationship with one SNF that could meet the needs of patients from many different communities. “Our relationship with one company decreased the barriers of having to form several relationships across the state and in the state of Washington,” Leitch explains. “We have an agreement with one company that has different locations. At a corporate level, they would help us with what would be the right location for each patient.”
The program identified SNF nurse skills and training as one of the barriers. The hospital provides additional educational training to nursing staff on how to support certain medical and behavioral medical health needs. They also added services to help with discharge planning and finding adult care placement, assisted living placement, and long-term care placement after rehabilitation at the SNF.
“We’ve added dedicated staff to this program as well,” Leitch says. “Acute care managers help our inpatient case managers in reviewing patients for medical readiness and appropriateness for admission.”
Assessing patients for referrals to SNFs is a process that is continuously tweaked and improved. At first, the leadership team identified all the patients appropriate for the transition program. Now, the case managers have learned how to identify the best candidates and make their referrals directly to the post-acute case manager for review.
“All of the leaders have transparency and awareness,” Leitch notes. “There are emails for all referrals, so we can see the types of patients coming through and who needs to be identified for placement.”
Then, the SNFs give the hospital priority for their available beds. “We reserve a certain number of beds for availability,” Leitch says. “We get prior authorizations for placement before the patient is transferred.”
Part of the reason the transitions have worked so well is because the hospital helps train SNF staff on skills they may not already possess. Hospital nurses train a liaison from each SNF on how to handle complex wound care patients and to provide trauma-informed care. “They also can apply these skills to patients who are not part of the program,” Ghassemi says.
Because the program became more virtual during the pandemic, the hands-on learning part was handled with just one nurse per SNF attending in-person hospital training sessions. Then, that person would become a trainer for their facility’s staff. “The skilled nursing facility has a dedicated liaison who is also a nurse,” Leitch says.
The liaison also can visit patients in the hospital if they are not sure if staff can meet a patient’s needs. “They’ll see the patient in person. If needed, they’ll go through whatever treatment and wound care is needed,” Leitch says. “The liaison comes on site, and it’s train-the-trainer.”
Much of the training takes place in the weekly calls. For example, the SNF nurse may ask a question about the patient’s outpatient antibiotic therapy. Both hospital and SNF staff evaluate patients for admission to the program.
“We work closely with the facility to develop exclusion and inclusion criteria to help identify patients they can support,” Ghassemi says. “There’s a support person in the case management department, and their entire role is supporting the reserved bed program. They work directly with everybody else on our team to support the referral and to pass them on, if appropriate. They provide ongoing education to our team to make sure everybody has a good understanding.”
The case management support person is involved in weekly calls to receive updates on patients enrolled in the program and to ensure treatment goals are met. “The first part of the discussion is about where the patient is with the goals,” Ghassemi says. “The second part is to help us understand what we can do to support that patient.”
For instance, medical equipment might be delayed. “That call is every week, and we discuss every patient that is currently enrolled in the program. It’s really valuable time for everyone involved,” Ghassemi says.
A health system tackled the challenges of transitioning patients to SNFs through a relationship with a multisite SNF. Together, the organizations created a bed reservation program, which results in a smoother and more effective transition process.
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