Care Transformation Center Blog

How Cedars-Sinai made SNFs its readmissions reduction partner

by Emily Boudreau

Approximately 20% of Medicare discharges from acute care hospitals are referred to skilled nursing facilities (SNFs), making coordination protocols with SNFs and other post-acute providers an imperative to avoid readmissions and lower total cost of care.

To improve care team collaboration and transitions of care for SNF-bound patients, Cedars-Sinai Medical Center founded the Enhanced Care Program. Through this program, Cedars-Sinai delivers care transitions services to 8 SNFs in their market at no cost to the SNFs. Cedars-Sinai has seen a 25% reduction in 30-day readmissions from participating SNFs.

I sat down with Bradley Rosen, MD, MBA, FHM, Director of Care Transitions and Complex Medical Management, and Rita Shane, PharmD, FASHP, FCSHP, Chief Pharmacy Officer, at Cedars-Sinai Medical Center to discuss the Enhanced Care Program.

We performed a survey and learned what patients want from PAC delivery

Nurse-practitioner led transitions

Normally when a patient is discharged from the hospital to a SNF, an attending physician at the SNF coordinates care and manages follow-up. While these physicians provide exceptional clinical care, many of them are too busy to frequently visit SNF patients and coordinate appropriate follow-up with other caregivers.

Through the Enhanced Care Program, a Cedars-Sinai nurse practitioner (NP) becomes the lead liaison. The NP communicates regularly with the patient's attending physician, but also with inpatient care teams.

Tactics for expanding AP roles and strengthening AP-physician collaboration

This handoff begins before the patient is transferred with an Inter-Facility Transfer Report detailing inpatient notes and key pieces of hand-off information. Within 24 hours of admission to the SNF, the NP visits the patient at the SNF and reviews admission orders. After this initial visit, the NP visits the patient 1-2 times per week as needed.

In the event of a change in condition or test results, the SNF calls the Cedars-Sinai NP first, instead of the attending physician. The NP then coordinates with all parties to determine the appropriate next step.

Don’t underestimate the value of medication reconciliation

After beginning the Enhanced Care Program, Cedars-Sinai realized one of the most critical issues was establishing an accurate medication list once the patient was admitted to the SNF.

“One of the largest problems was that there wasn’t a single, clean medication list. [The SNFs] sometimes received multiple lists with different medications on them, and the SNF nurses had to try and reconcile them.” —Rita Shane

Now, within 24-72 hours of SNF admission, the SNF sends the patient’s SNF admission medication list to the Cedars-Sinai pharmacy department, where a pharmacist reconciles the SNF medication list with the inpatient discharge medication list, clinically evaluates the reconciled medication list, and communicates any issues to the NP liaison. The results have been dramatic, with the pharmacy department identifying and correcting drug errors in 50% of participating patients.

Identify specific opportunities to create a coordinated care pathway

“While delivering services is a large part of this program, we’re also working with the SNFs to identify shared areas for clinical improvement.” —Dr. Bradley Rosen

Since the advent of this program, they’ve also created a blood transfusion protocol for the Enhanced Care Program. In the past, attending physicians would often send anemic SNF patients back to the hospital for blood transfusions, even if these patients were clinically stable, which contributed to higher ED utilization and readmission rates.

Cedars-Sinai worked with the SNFs, the outpatient infusion center, and the blood bank to change protocols around these patients. Now, Cedars-Sinai’s Enhance Care Program team provides outpatient scheduling, type and cross for blood, and transportation for anemic patients to the outpatient infusion center.

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