Montefiore Medical Center’s Regional Nursing Home Collaborative: Innovations in Post-Acute Care Transitions and Reductions in Readmissions
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Montefiore Medical Center’s (Montefiore) Care Management Organization (CMO) initiated a unique collaboration with five of the community’s skilled nursing facilities (SNFs) that serve the highest volume of Montefiore patients, with the goal of reducing avoidable readmissions of patients discharged from the acute care setting to a SNF. The objectives of the collaboration were to increase knowledge of evidence-based guidelines, improve communication between acute and post acute providers, improve the quality of care and quality of life for patients, and reduce preventable acute care readmissions. The impetus for establishing the program stems from several factors:
- Montefiore patients affected by this program are cared for under a global payment structure, which holds Montefiore financial liable for the health outcomes of patients.
- Montefiore patients face complex social challenges in their communities, and require more from their providers that just excellent inpatient care to ensure they remain healthy.
- Medicare’s program to reduce payments for avoidable readmissions went into effect in 2012.
- Montefiore experiences higher than average incidence of readmissions.
- The Bronx has 43 SNFs with approximately 12,000 beds. Montefiore contributes 8,000-10,000 discharges to SNFs annually.
- Research findings confirmed higher rates of readmissions by Montefiore patients residing in SNF’s.
*2012 Readiness for Reform (R4R) Innovation Challenge
- Facilitate and support the training of geriatrics fellows within the Einstein-Montefiore Geriatrics Fellowship Program by providing exposure to innovative programs both within the geriatric inpatient setting and the post-acute care SNF setting.
- Improve care for patients by leveraging research findings produced by Einstein to identify gaps in care at Montefiore and among SNFs in the Bronx Community.
- Establish new best practices in care management and communication that are immediately folded into programs for medical students, residents, and fellows training in internal and family medicine and geriatrics, as one mechanism to meet ACGME requirements for the Next Accreditation System (NAS), to prepare graduates for the “future” health care delivery system.
- 2012 Readiness for Reform (R4R) Innovation Challenge, Care Transitions, Nursing Home/Skilled Nursing Facility, Cross-Institutional Provider Collaboration, Best Practices, Knowledge Transfer, Readmissions, Advanced Care Planning, Geriatrics
- Family Medicine
Interpersonal & Communication Skills
End of Life Care
Evidence Based Practice
Information Management/Computer Applications
Practicing Health Professional
Allied Health Student
- Allied Health Student
Professional School Post-Graduate Training
Authors & Co-Authors
Kate Rose, MPH
Montefiore Medical Center, University Hospital for Albert Einstein College of Medicine
Anne Meara, RN, MBA
Montefiore Care Management
Alexander Alvarez, RN
Montefiore Care Management
Lynn Richmond, NP, MS
Montefiore Medical Center
Amy Ehrlich, MD
Montefiore Medical Center
Effectiveness and Significance
Evaluation & Measurement
Self-reported readmissions rates are the primary measure of success for the program right now. Updated data on readmissions is shared among the five SNFs and Montefiore on a monthly basis during their in-person meetings. Using Montefiore patients’ readmissions rates as the baseline, we have seen the Montefiore 30-day readmissions rates drop from 33 percent in 2010 to an average of 15 to 20 percent currently. Anecdotal data being gathered at one of the SNFs piloting full implementation of the advanced care planning initiative has reported that the number of palliative care and hospice consults conducted in the past three months eclipsed the number completed in the previous 18 months – a 500 percent increase if this rate were to continue. In the future, Montefiore plans to refine their measurement of readmissions, including expanding use and reporting of palliative and hospice care consults to understand its impact on readmissions. In addition, the group has also agreed to work on two key quality measures included in the CMS Nursing Home Compare data—percent of residents reporting pain and percent of residents with a urinary tract infection. Collaboration in this area will focus on achieving performance levels that meet or exceed state and national averages across all five SNFs through the sharing of QI initiatives and associated best practices.
- Improved quality of life for patients and caregivers through a reduction in transitions back and forth between acute and post-acute care, reduced tests and medical procedures, and general understanding of and adherence to the wishes of patients.
- Eased stress in the work place for providers because they understand clearly the wishes of a patient and/or their caregiver for the course of treatment.
- Reduced preventable readmissions and unnecessary costs in the system.
- Strengthened relationships with key community partners.
- New opportunities for shared learning emerged that were not identified at the outset, but will be implemented when the program expands.
- Affirmed the program should expand in the future to the next tiers of facilities serving Montefiore patients.
Special Implementation Guidelines or Requirements
The program uses three primary interventions to establish new evidence-based protocols and care pathways support the program objectives:
- Implementation of the core interventions encompassed by the INTERACT ™ program, including the Quality Improvement Tool for Review of Acute Care Transfers; the “Stop and Watch” pocket card and report early warning tool; and, the SBAR communication tool and progress note.
- Regular opportunities for knowledge transfer and improved communications between acute care and post-acute care environments through new relationships, monthly meetings among all SNFs and Montefiore’s program leads; and
- Standardized protocols for discharge planning, including the development and staged implementation of standardized processes to consistently perform advanced care screening and planning.
The program’s success depended on several key factors:
- Strong relationships between Montefiore’s Care Management Organization and the community SNFs;
- Trained and engaged SNF staff; and
- Well-developed relationships between Montefiore's Geriatrics Division, including its hospitalists, and community SNFs.FOR COMPLETE TEXT DOWNLOAD FULL DESCRIPTION
- (Anticipated) Despite the best of intentions, medical staff located at both inpatient facilities and post-acute care facilities fail to follow evidence-based guidelines for discharge planning and post-acute care management.
- (Anticipated) Due to the evolving nature of evidence-based medicine, providers in the post-acute care setting are not always up-to-date on best practices. Their resources are limited to maintain their knowledge base, and they benefit greatly from shared knowledge and support (both educational and staff) from other community partners.
- (Unanticipated) There are opportunities to greatly expand shared learning and problem solving between acute and post-acute care providers. For example, Montefiore and its SNF partners established complex case response teams – these are cross-institutional teams that meet to discuss options for improving the quality of care for patients with complex medical and/or psychosocial issues contributing to preventable utilization.