“We are proud to be at the forefront of this effort,” said Barbara Bailes, executive director at Life Care Center at South Mountain, “and we love welcoming all our community partners into our facility each month!”
Two groups meet monthly at the facility. One focuses on Life Care Center at South Mountain. Physicians, home health providers, hospice workers, mobile physicians and other health care workers review the month’s data on residents who have bounced back (returned to the hospital within 30 days of admittance to the facility). The group discusses trends and brainstorms ways to reduce the number of re-admits to the hospital.
The second monthly meeting is a community forum in which health care workers across the spectrum strategize ways to improve partnership and continuity of care. Since the program began in July 2012, attendance has grown from a dozen partners to more than 130. Attendees include chief medical officers, case managers and discharge planners from community hospitals, mobile doctors, home health and hospice providers, laboratory clinicians and dialysis workers.
Several helpful ideas have come out of these meetings so far.
In November, Life Care Center at South Mountain identified a need for communication protocols for patients discharged from the facility to home.
“We have intensified our efforts to discharge all patients with a scheduled appointment with their primary physician, something that has proven challenging in the demographic we serve,” said Bailes. “We are now coordinating with our home health partners to use mobile doctors and nurse practitioners when appropriate. With these two interventions, we anticipate improved outcomes for our more vulnerable discharged patients.”
Brooke Aloe from Gentiva Home Health, shared her perspective on the meetings.
“The meetings have been an invaluable resource that have brought together all of the key players in a patient’s discharge from the skilled nursing setting,” Aloe said.
“We have a better understanding of how each other works and what information is most critical for each other’s success. This leads to a better transition home for the patient and a more successful discharge all around.”